Top Priority: Addiction

Joseph A. Califano was Lyndon Baines Johnsons chief domestic aide in the mid-1960s and 10 years later (the last) secretary of health, education and welfare, until July 1979, after President Jimmy Carters famous malaise speech. In his acknowledgement for this new book, he mentions his Jesuit formation (he uses that phrase) at Brooklyn Prep and the College of the Holy Cross and then Harvard Law School as he gives an account of the arduous work required to obtain philanthropic support for the 1992 founding of the National Center on Addiction and Substance Abuse (CASA) at Columbia University.

High Society similarly reflects this Brooklyn-born, well-connected D.C. lawyer and Democratic Party insiders jury-swaying powers of persuasion. He tells us that the problem of substance abuse and addiction is more than an epidemic, that it is a pandemic so severe that it requires a substance abuse Manhattan Project, a National Institute on Addiction (combining the current Institutes on Alcoholism and Alcohol Abuse and Drug Abuse), and that the United States should put this issue at the top of its foreign policy agenda, along with trade, nuclear proliferation, and terrorism. This lawyer has the facts, a plethora of them. The book closes with a 46-page index and Source Notes (including the U.S. Dept. of Health and Human Services, National Household Survey on Drug Abuse, National Institute on Drug Abuse, AMA and CASA, to mention less than a third of them), which make Califanos stirring address to the jury of public opinion a veritable encyclopedia of social science drug research.

The numbers are indeed sobering. Here are a few: The overall direct costs of smoking and alcohol abuseincluding health care, crime, lost productivity, disability and social welfare for affected people like abused children and those who lose parentsis now approaching a trillion dollars annually. The appendix, Diseases/Conditions Attributable to Substance Abuse, lists 85 disease categories, then the substance and its population attributable risk, that is, the percentage of a given illness that could be prevented if the use of the substance were eliminated. Some examples: alcohol and smoking are responsible for 80 percent of the incidents of esophageal cancer, smoking for 88 percent of male (74 percent of female) lung cancer, smoking and cocaine for 41 percent of spontaneous abortions. For reformers and voters, Califano documents both the mega-lobbying monies of the tobacco and alcohol industries and their subtle courting of the young. Almost half of high school students admit drinking in the past month, and of those who drink, 67 percent of the boys and 61 percent of the girls binge drink. Califano is attuned to the gender differences involved in substance abuse and the current corporate efforts to appeal to girls and minorities.

In a chapter entitled Follow the Tobacco and Alcohol Money, Califano calculates that underage drinking is a key to the profitability of the alcohol industry not merely because young drinkers are a source of almost a fifth of its revenues but because they also become the adult dependent drinkers who are the source of at least another 20 percent of industry profits. Califano informs parents, many of whom remain willfully blind to teenage substance abuse, that a child who gets through age 21 without smoking, using illegal drugs or abusing alcohol is virtually certain never to do so.

In these sections he also says some cogent things about treating substance addiction as a disease in terms of public policy while not avoiding the topic of personal responsibility. True, individuals who inhale their first joint, swallow their first drink, snort their first line of cocaine, or pop their first pill are certainly responsible and can be held accountable for their conduct. If they had never experimented in the first place, they wouldnt have gotten hooked or become abusers. But most people who make that first choice do so at an age when they are not capable of appreciating the consequences of their choice.

There is much more in this encyclopedic lawyers brief than alcohol and smoking. His data and analyses deal with heroin, cocaine, crack-cocaine, the designer drugs of the 1990s (ecstasy, methamphetamines); the frighteningly wide misuse of over-the-counter allergy drugs and prescription drugs like Ritalin and Adderall; the relationship between polydrug abusers (that is, most addicts) and marijuana as a gateway drug; cross-cultural experiences of other nations efforts at decriminalization (unsuccessful, in his eyes); the research on 12-step programs like Alcoholics Anonymous and the fierce internal debates about the best substance abuse treatments.

From a social policy point of view, I found the most compelling points in the section shoveling up money, in which Califano powerfully calls attention to the fact that to pay for the messes in personal lives and families and society caused by substance abuse, out of every tax dollar spent in this domain we give 96 cents for more police, judges, emergency rooms, social workers and, especially, jails, instead of vastly increasing the amount (4 cents) we give for prevention and treatment.

While Califano includes several references to the role of religion and the faith communities, it is mostly in terms of the positive impact of religious belief and participation on addict recovery. What is also needed is a religious-cultural-anthropological reflection on why we are in this areaas in military spending and economic inequalitynumber one in the world.