People in Africa talk about five natural disasters: fire, flood, famine, earthquakes and government. Tonight I would like to explain why government policies around the world ensure, inadvertently, that drugs like heroin continue to be a slow-motion natural disaster. There are many easily identifiable reasons why governments find it extremely difficult to respond to illicit drugs in affordable and effective ways.

Last year I attended a meeting in Hanoi that was addressed by Mr. Hans Emblad, then Director of the Program on Substance Abuse, World Health Organization. Previously, Mr. Emblad had been Deputy Director of the United Nations Drug Control Program, which is responsible for coordinating international narcotics control. Mr. Emblad explained that for 20 years he had attended international narcotics control meetings. These meetings always began with a review of the global narcotics situation. Invariably, after reviewing international developments over the previous 12 months, participants would agree that the global illicit drugs situation had deteriorated alarmingly. The second part of ate meeting involved preparation of recommendations for further action. Invariably, the participants would recommend an intensification of existing law enforcement approaches. Mr. Emblad commented that after two decades, he now saw that drug policy had to be fundamentally reconsidered.

Until a few years ago, support for reform of drug policy was considered somewhat radical. Now support for drug policy reform is common among clinicians, researchers and even parents of children who have died from a drug overdose. Many politicians and senior police accept privately that drug policy reform is both desirable and inevitable. Public opinion is changing. Research conducted for the Commonwealth Department of Health a few years ago showed that about three-quarters of the community support modest reform of cannabis policy when the question was framed in a neutral manner. Drug policy reform is not an issue just of interest to a handful of academics and a tiny minority of drug users. Prohibition affects everyone who pays taxes, everyone who pays domestic insurance, everyone who is worried about getting their handbag snatched. As with many reforms, the odds against change currently seem insurmountable.

Drug policy reform is inevitable because it is now inescapable to many well-informed people who recognize that illicit drug law enforcement is expensive, ineffective and counterproductive. Additional resources for police, customs, or prisons and more severe penalties have not made and will not make illicit drug law enforcement any more effective. George Shultz, former U.S. secretary of state, pointed out that illicit drug law enforcement will not work because the conceptual basis is "fatally flawed." The fatal flaw is an attempt to defy economic gravity. We seem unable to significantly decrease the demand for drugs we have classified as illicit. While a demand for drugs like heroin exists, there will be supply. If heroin is not supplied by a legal source, it will be supplied by an illegal source. It is as simple as that. Law enforcement imposes a value-added tax on illicit drugs that is collected by criminals. The more severe the penalties and the greater the chance of detection, the more lucrative the trade and the higher the profits.

The scale of the global illicit drug industry is astonishing. The global illicit drug industry has an annual turnover larger than Australia's GDP, twice the size of the pharmaceutical industry or five times bigger than the global iron and steel industry. Annual profits may be as much as $350 billion. Almost 10 years ago, a Federal Parliamentary Committee estimated that the Australian illicit drug industry had a turnover of $2.7 billion. The Queensland Criminal Justice Commission estimated that cannabis was the second biggest agricultural crop in the state after sugar. And some will have you believe that the drug problem will be improved by more and bigger speed bumps or a few more prisons!

Developing more effective policies is complicated by the fact that logic and rationality have a relatively minor influence on the way communities respond to drug problems. Current policies have no pharmacological or public health basis. Two hundred Australian children take up tobacco smoking every day. About a quarter will ultimately die from their favorite drug. Cannabis has not yet been credited with a single death in scientific literature. Yet, while boards of legal tobacco companies comprise the pillars of the community, criminals monopolize the supply of illegal cannabis. If policy was based on harm to the community, cannabis would be legal and tobacco illegal. Prohibition was not developed following a careful review of evidence and a consideration of the benefits and costs of available options. Our laws about illicit drugs are arbitrary and capricious. Prohibition makes it likely that more dangerous drugs replace less dangerous drugs and more dangerous routes of administration replace less dangerous routes of administration. So opium smoking by old men in Asia was replaced by heroin injecting in young men. Denial practiced on individual, state, national and international levels is another obstacle. As Eliot said, "mankind cannot bear too much reality." Our problem is how to dismount the tiger's back.

Many members of the community are concerned about drugs. Drugs, unemployment and the threat of nuclear warfare are usually ranked among the issues that concern ordinary members of the community. Developing effective and affordable policies for illicit drugs is obstructed by symbolism and powerful myths. Illicit drugs are seen as forces of utter depravity, inevitably enslaving and instantly corrupting those who consume them. Communities have as much difficulty controlling their responses to illicit drugs as some individuals have controlling their consumption of these substances.

Why did I become interested in drug policy? In 1987, while studying how other developed countries responded to the threat of HIV among injecting drug users, I spent an evening observing a shooting gallery in Brooklyn, New York. The scene outside was like war-torn Bosnia. Ruined tenement apartments were abandoned. Cars with smashed windscreens were propped up on bricks. We entered a pitch-black building with no electricity and descended to a dark, foul-smelling basement to watch four Hispanic men and women injecting "speed balls" made of heroin and cocaine. It was a scene of utterly desperate squalor, filth and misery. The four injectors fumbled around in the darkness looking for their needles and syringes. Blood dribbled freely from their injection sites. Although I have seen many poverty-stricken parts of the developing world, this was a truly devastating experience.

Why, I asked myself, did New York City have shooting galleries of this kind and Sydney did not? The answer was clear. Carrying a needle and syringe in the streets of New York city is so dangerous that few are prepared to take the risk. Secreting illicit drugs in clothing or a body cavity is much less hazardous. So drug injectors buy their drugs and usually go to a shooting gallery where they can rent a needle and syringe for a few hours. There must be cheaper ways to spread epidemics of blood-borne viral infections (like HIV and hepatitis C) but it is hard to imagine a more efficient system.

After this experience, I began to read intensively and find out more about drug policy. Almost everything I read concluded that illicit drug law enforcement was a costly, ineffective and co,un ter-productive exercise. Although Australia spends somewhere in the region of half a billion dollars every year, illicit drugs of diverse kinds are readily available and drug-related crimes continue to increase. Each year, about 500 young Australians die from drug overdose, which is roughly the number of servicemen Australia lost in the Vietnam war. An estimated 6,000-8,000 young Australians become infected with hepatitis C each year through drug injecting. Unscrupulous criminals become rich beyond their dreams.

A chorus of senior, influential and well-respected citizens now say that prohibition is not working and cannot be made more effective. If their arguments are so strong, why has there been no change? In a world where we increasingly consider government policies from a commercial perspective, why do we tolerate policies with such a poor return on an annual investment of half a billion dollars a year? A well-regarded Rand study showed that the return to the United States on an investment of $1 spent to reduce cocaine problems was 17 cents for coca plant eradication in the Andes, 32 cents for interdicting between Colombia and Florida, 52 cents for supporting U.S. Police and Customs and $7.48 for treatment for cocaine users. The United States allocates 93 percent of its cocaine budget to measures that bring a return of 17 to 52 cents on the dollar and only seven percent of its budget to an intervention that returns over $7. Two recent Royal Commissions in Australia have concluded that police corruption and prohibition are linked closely. If we want our authorities to get tough on police corruption, we will have to insist that they get tough on the causes of police corruption.

Before considering why it is so difficult to change policies or what the alternatives might be, we should ask ourselves whether drug policy is the most important factor determining outcomes from illicit drugs. Most people involved in this field — including researchers, clinicians, law enforcement officers and drug users themselves — do not believe that prohibition or drug policy reform is the most important factor determining the levels of illicit drug use in Australia and harm created by such use. There is more to drug policy than drug policy. Prohibitionist Sweden and reformist Netherlands both have relatively good outcomes from illicit drugs while the prohibitionist United States and reformist Italy and Spain have dreadful outcomes. Whatever drug policy we have, the extent of illicit drug use and the harm resulting from illicit drugs will probably be much more influenced by levels of youth unemployment, educational and training opportunities, housing, and welfare. What should a young Australian growing up in a disadvantaged part of ône of our big cities do if there are no job opportunities, dwindling educational and training opportunities, and decreasing financial support for the unemployed? Inevitably, some will be attracted to illegal employment and illegal income if that is all there is available. An illicit drug industry answers many needs apart from a temporary pharmacological vacation. If there is so little reason to retain prohibition, why does it continue? Powerful myths are part of the explanation for the survival of prohibition.

Myth Number One is that decriminalization and legalization are the only alternatives to current policy. It is as if drug policy were a giant on/off switch with only three positions: prohibition, decriminalization and legalization. It does not seem to matter that these terms mean totally different things to different people. There is in fact a range of choices: total prohibition, prohibition with civil penalties, partial prohibition, regulation and free availability. Almost as important as these choices are the specific details of policy. Reform can also be achieved without changing legislation by simply changing police guidelines.

Myth Number Two is that drug policy reformers covertly support legalization so that drugs like heroin would become available without restriction from every grocery store and milk bar across the country. I know many people who work hard to achieve drug policy reform in Australia and overseas. Almost without exception, these people wish to see some kind of controlled availability where drugs like heroin would be available along similar lines to the current methadone programs. Following a clinical assessment, applicants deemed suitable would be admitted to treatment at a clinic and provided with heroin on a regular basis. This approach has been followed in parts of Britain since 1926. A similar approach evaluated in Switzerland for the last two years has proved to be very successful. The Netherlands and Spain are setting up trial programs to evaluate controlled availability of heroin. If legalization means making heroin as available as confectionery, it is as trenchantly opposed by drug policy reformers as it is by supporters of prohibition.

Myth Number Three is that reform of drug policy increases both consumption and problems as surely as night follows day. Unfortunately it is not as simple as that. This analysis is based on the assumption that if prohibition inflates prices and therefore depresses consumption, any reform inevitably decreases price and increases both consumption and problems. There is no doubt that prohibition tends to inflate the price of illicit drugs. But not always. Traffickers pay a premium on the risks they run. This premium is passed onto consumers who in turn pass on their premium to non-consumers (mainly through property crime). But it is wrong to assume that intensified law enforcement inevitably raises prices and depresses availability of illicit drugs or that reforms inevitably reduce prices and increase availability. While cocaine law enforcement was progressively intensified in the United States between 1977 and 1992, the price of cocaine (adjusted for inflation and increasing purity) dropped steadily by more than 80 percent and the number of cocaine consumers increased from two to nine million and then decreased to seven million. Who can say for certain what will happen to demand and supply if the premium on risk is reduced? Who can estimate the effect of prohibition or reform on any substitution between licit and illicit drug markets? Prohibition inflates the prices of illicit drugs by making drug trafficking more hazardous. Higher prices means greater profits. Higher profits attract new traffickers who then seek new markets. It is conceivable that the illegal drug market could be much smaller under reform than under prohibition. If we look around the world as prohibition has been intensified year after year, decade after decade, global drug markets have steadily expanded. If drug markets worked the way that prohibition supporters said they do, why have drug markets not been shrinking?

Even more important, we know that, at present, most problems attributed to illicit drugs including overdose and infections are related to the vicissitudes of an illegal market rather than being consequences inherent from the pharmacology of the forbidden substances. It is more a case of drugs being dangerous because they are prohibited than drugs being prohibited because they are dangerous. So reform is likely to produce a less dangerous market and may produce a smaller illicit market when profits decline.

It seems self-evident that we will never achieve progress in this area until the drug trade becomes less lucrative. The drug trade will only become less lucrative when an alternative source of supply challenges the current criminal monopoly. The only challenge can come from a source allowed by government. And that is one of the reasons we so badly need the proposed Australian Capital Territory (ACT) Heroin Trial. Present policies, whatever their intent, mean that criminals have a monopoly on supply.

Myth Number Four is that drug policy reform is political suicide. Many successful politicians in Australia have for some years supported drug policy reform openly. Drug policy reform is the official policy of the Australian Democrats, Young Labor and the Young Liberals. The Leader of the Oppo sition in New South Whales (NSW) advocated providing heroin to drug users in June 1984. Although Mr. Greiner was criticized for this at the time, he went on to become premier four years later. Peter Baume, now professor of Community Medicine at the University of NSW and Chancellor of the Australian National University, was a Liberal Senator for NSW for 17 years. During most of that time, he had the number-one spot on his party's ticket. His support for drug policy reform was well-known. It did not stop him from becoming a most distinguished federal minister. If we look around, there are many examples of politicians who have openly supported drug policy reform and continued to prosper. Mr. Michael Moore of the ACT Legislative Assembly has been re-elected twice after strong and open support for drug policy reform. Ms. Ann Symonds of the NSW Upper House has been equally forthright and was number two on her party's ticket at the last elections. There are now almost a hundred parliamentarians around the country who have signed a charter for drug policy reform. Most are still serving in parliaments today. Even in the oppressive political climate of the United States, support for drug policy reform is not incompatible with political survival. Kurt Schmoke, a black Rhodes scholar, is the mayor of Baltimore in the United States. He has openly supported drug policy reform for almost ten years. Drug policy was one of the major campaign issues that Schmoke fought in 1995 when he was re-elected mayor for the third time. Support for drug policy reform did not stop Mayor Schmoke from being invited to a cabinet position in the Clinton administration.

What do we need to do to get out of this mess? We need to recognize that we have to develop policies for the world as it is now and not the world as we might like it to be. It is better to set achievable goals and meet them than fail to reach utopian objectives. Specifically, we need to:

1) Recognize that drugs currently classified as illicit should be primarily treated as a health matter rather than a law enforcement problem: this will produce considerable net benefit to the community;

2) Recognize that demand for drugs like cannabis and heroin is likely to remain much as it is now for the foreseeable future;

3) Recognize that where there is a demand for drugs, a source of supply inevitably develops: if a legal source does not exist, an illegal supply will develop;

4) Recognize that we will never achieve progress without reducing the profits of traffickers: we will only reduce the traffickers' profits if legal supplies undermine the profitability of the illegal supply;

5) Some people, determined to get drugs whatever we do, now get adulterated supplies of unknown concentration from criminals: we need to find out whether the community and these people are better off if they can obtain sterile drugs of known concentration from government clinics:

6) Cannabis should be considered separately from drugs like heroin with policies for all drugs causing less harm than the drugs do;

7) All reforms must be incremental with evaluation of intermediate stages;

8) Initially, increased police discretion covered by specific guidelines is the most achievable reform for cannabis and other illicit drugs: ultimately, regulated production and sale of cannabis is inevitable and the least worst option for cannabis consumers and the general community;

9) Efforts to reduce demand for drugs should be expanded including community and school drug education (expecting only modest and long-term gains) and drug treatment (especially methadone and other pharmacological treatments);

10) We should continue to support law enforcement efforts against major traffickers (as we do for major traffickers of drugs like alcohol and tobacco).

Drug policy reform can only happen politically with multi-party and Commonwealth/State mechanisms. This follows the successful model developed during the mid-1980s for the National Campaign Against Drug Abuse and our HIV/AIDS strategies and gun law reform in 1996.

Drug policy reform is now inevitable. It will happen incrementally and primarily be driven by fiscal concerns. When cannabis reform was introduced in the Northern Territory, the government justified the policy change entirely on fiscal grounds. Reform will happen faster if we find better ways of getting the policy camel to pass through the eye of a political needle. This requires the issue to be taken out of the 36- or 48-month political cycle and sorted out on a national basis while accepting the power of market forces. It will happen faster if we develop better answers to the question "Yes, Alex, but what's in it for me? Why should I try to push the envelope?" Politicians are generally more comfortable following than leading public opinion. But they are prepared to lead if public opinion appears to be catching up with the views of opinion leaders and if policies are salable. What makes drug policy reform eminently salable is the youth vote for cannabis and the appeal for older voters of a reduction in property crime, insurance costs, security costs and police corruption.

The Serenity prayer uttered by followers of Alcoholics Anonymous all over the world asks God to provide acceptance for the things that cannot be changed, courage to change the things that can be changed and the wisdom to know the difference. This prayer is relevant to people worried about their community's response to drugs as it is to people worried about their alcohol consumption. We need to begin accepting the reality that many members of communities all over the world have sought, and will continue to seek, mood-altering drugs. We need to accept that our responses to this drive are often more harmful than the substances themselves. We need the courage to change those man-made laws that can be changed and that create more harm than they prevent. And we need the wisdom to recognize things that cannot be changed and select from prohibition that which is worth keeping.

Alex Wodak, MD, is the director of Alcohol and Drug Services at St. Vincent's Hospital in Sydney, Australia. Dr Wodak received the 1992 Norman E. Zinberg Award for Achievement in the Field of Medicine & Treatment.