Healthy Dying

 

This post was inspired by a recent Tricycle article, “Death as a Spiritual Experience.” Our culture is so death phobic, yet paradoxically so entertained by violent death, that the idea of healthy dying seems counterintuitive. The much touted public health concept of “Healthy Ageing” conveniently omits the final chapter — dying, which would seem to contradict, or at least undermine, the goal of health.  How could dying possibly be healthy?

The rational solution to the problem of assuming that dying must be unhealthy, is of course government approved “physician-assisted” dying or euthanasia.  An alternative approach, which considers dying a natural process and an opportunity for healing, is of course palliative care. Offering support to patients and families through the illness, dying, and bereavement process alleviates a measure of suffering by offering to mend  breaches of connection, or heal relationships between family members. These include breaches within the self, failures to connect with, and love parts of yourself you have always despised. The transition out of the body that we call dying will be much more painful for all concerned until we accept all those parts. Doing so restores us to wholeness, or health.

Tibetan Buddhism is one of the few religious practices that directly confronts the experience of dying with a forensic, phenomenological approach that takes the transition to other vibrational realities seriously. Christianity also takes it seriously but is based on the third person perspective, or the idea that we each can mystically participate in the dying experience — the Passion — of the Christ. Doing so does not necessarily demand that we be the witness to our own dying, though.

And Vipassana teacher Larry Rosenberg points out: “most of us are imbalanced when it comes to death. We haven’t come to terms with the nature of our bodies, and we don’t see death as a natural process. So we have all kinds of funny reactions to it: excessive joking, or avoidance, or preoccupation in a morbid way. Death awareness practice can bring us into balance.”

tibetan-book-of-the-dead

We can practice for dying simply by becoming aware of our breathing — of each outbreath that might be the last, and then the next and the next and the next. Making all our living in awareness of the outbreath a practice for dying enables us to  directly experience the present moment, rather than experience in a mediated way, as narrated, or not be experienced at all.

I aspire to experience all my dying: after all, it may be the only time I do it in this body, and it would be a shame to miss out!

Reducing harms of ‘harmless’ pleasures

My effort to learn as much as possible about international drug policy brought me two interesting films last week, “Sicario” and “Cartel Land.”  The following reflections are based on what I got from those films: first, both made it clear that people in high income countries who use illicitly produced and trafficked drugs recreationally (non-problematically) are accessories after the fact to drug war violence/harms in producer and transit communities, including urban neighbourhoods. Engaging in political action to promote decriminalisation and regulated access to what are now illicitly sourced psychoactive substances could be a powerful form of drug user harm reduction. Supporting civil society activities in countries where CSOs are weak or repressed, while personally boycotting illegally sourced substances altogether until goals are achieved, is another. People are more than just consumers (of all commodities, not just illicitly trafficked drugs); they are also citizens enmeshed in a global political economy that creates public bads as well as public goods.  And ethical consumerism must extend to our all our pleasures.

The harm to be reduced arises from the illicit drug market, or ‘state of nature,’ where personal security is non-existent, and life ‘nasty, brutish, and short.’ Such is the existential context of producer and transit environments. When governments themselves cannot provide security for their citizens, the state of nature prevails, and people must defend themselves in the “war of all against all,” until a new “sovereign” emerges to protect them.

The invisible hand of the market created by recreational and problematic users in high income countries generates these violent parallel “states” [of nature] in producer and transit countries where governments are weak and often illegitimate. The law of the strongest and best supplied — Thomas Hobbes’ war of all against all — co-exists alongside the laws of governments selected by citizens via elections, or appointed by military coups.

Their social contract duty to protect citizens renders governments that tolerate, let alone profit from, the existence of parallel states, liable for drug war damage to their own citizens, as well as to citizens of other states. Governments and agencies that fail to protect forfeit domestic obedience and legitimacy in the international community.

Other narratives of transnational ethics of solidarity and mutual aid, which can provide protection for vulnerable communities, are possible. The Michoacan self-defense forces in the documentary film “Cartel Land” did exactly that at first, providing security for communities ravaged by cartel violence and unprotected by official forces. “There is no government. The government is often working with the criminals,” said the people. Citizens in towns that were not so hard hit, who continued to believe in the state, took the opposite perspective and refused to join the Autodefensas, saying “If we don’t believe in the institutions of the state we are finished as citizens.”

Members of drug policy reform organisations in the high income countries can act as responsible global citizens by acknowledging their consumer communities’ partial complicity in the cycle of violence.  Civil society organisations that take responsibility for their part in strengthening the “invisible hand” of the market for illicitly trafficked substances can work authentically to end the cycle of violence. After all, it is demand from the rich countries that keeps the cartels in business and the state of nature flourishing.

Taking an ethical/political stance doesn’t mean playing the blame/victim game or stigmatising people who use drugs, but acknowledging  responsibility for consumer habits that expose “bystander” individuals and communities to cartel violence and government repression. Those vulnerable ‘other’ communities are found in what Latin American theologian Jon Sobrino SJ calls “entire crucified continents”.

“Cartel Land” drives home how ordinary people, usually poor people, pay with their security, peace of mind, and their lives, to satisfy the northern hunger for their products. Participating in consumer advocacy initiatives to change repressive drug control laws that benefit the cartels would be one way recreational users could take responsibility, pay for pleasure bought with blood money.

Media induced hype about the so-called “opioid abuse epidemic” in the US, Canada, and Australia, is already damaging patients and families in countries with low to no access to medical opioids for pain and palliative care. The exaggerated threat posed by prospect of widespread non-medical use of opioids now supports governments’ unwillingness to identify and remove barriers to legitimate access, making advocacy much more difficult.

Organisations in high income countries with strong civil society sectors can campaign to pressure governments to reduce the harms of the drug war and support NGOs in countries where they are weak or suppressed. They can also facilitate inter- governmental and UN agency collaborations for good public policy outcomes, requiring political appointees and bureaucrats to step out of institutional comfort zones.

Advocacy means active and responsible participation in institutions such as the Civil Society Task Force organised for UNGASS2016, and hopefully set to continue until the next drugs UNGASS in 2019. The CSTF can remind governments whose citizens use illicitly sourced drugs either recreationally or problematically, that they have a duty of care to support evidence-based policies that reduce the harms of such use. Policies include decriminalisation, prevention, treatment, harm reduction, reintegration services, and the rational use of controlled medicines for the treatment of pain and suffering.

Governments that promote hard line, exclusively supply control, drug policies at the UN, clinging to the largely fractured “Vienna consensus,” and boycotting the health and human rights based approach promoted by the Geneva institutions, claim to be “protecting” their citizens from these parallel governments. As they are often besieged from within and without, such governments use their monopoly of “legitimate” violence to suppress the trade, failing to produce the desired effect while generating multiple harms. One way to diminish these harms is to build the capacity of civil society organisations (CSOs) to hold governments accountable, an approach that does not appeal to countries ruled by precarious elites.

Nation states and drug cartels are not the only powerful institutional actors in the international community. Transnational civil society networks can also be powerful, which is why some member states discourage them. Member states that favour moving away from exclusively militarised solutions to the world drug problem, could contribute to the emerging public health paradigm by supporting capacity building for CSOs in countries where civil society is weak and in need of support.  And let’s take ethical responsibility for our guilty pleasures by committing to harm reducing political advocacy at the local, national, regional, and global levels inter alia! 

meth cooks

Sturm, Drang, and the Busted Drug War Consensus: The Decline of International Law

Sturm, Drang, and the Drug War. The Decline of International Law Katherine Pettus, PhD There is a great deal of Sturm and Drang afflicting the leading lights of the drug policy reform community at …

Source: Sturm, Drang, and the Busted Drug War Consensus: The Decline of International Law

Sturm, Drang, and the Busted Drug War Consensus: The Decline of International Law

Sturm, Drang, and the Drug War. The Decline of International Law

Katherine Pettus, PhD

There is a great deal of Sturm and Drang afflicting the leading lights of the drug policy reform community at the moment concerning the “breakdown of consensus” of UN drug policy and gloom over the prospect of anything new or progressive coming out of the UNGASS in New York next week.  What was once global drug policy based on international law, is more likely to drift into loose alliances based on convergences of national and regional interests.  In the words of international relations scholar Hans Morgenthau “Where there is no balance of power and no community of interests, there is no international law.” There is no consensus at CND on “harm reduction,” the death penalty for drug offences, evidence based treatment, or just about anything concerning drug policy, except (fortunately) the need to ensure the provision of controlled medicines for the treatment of pain and suffering.  That is because there is no longer any community of interest at the UN and no balance of power.

While critical international relations theory can easily explain the first part of the equation — the Sturm about the breakdown of consensus at the UN level — the Drang, or fury, that nothing progressive is likely to come out of the watershed meeting —  reveals general public naïveté about international relations in general and the UN system in particular. As a member state organisation the UN is based on sovereignty and equality of all its members.  Membership requires neither democratic credentials nor adherence to human rights standards.  Positions issuing from the General Assembly necessarily reflect the range of shifting political realities, national interests, and imperatives to which each state is subject. It rarely, if ever reflects a global civil society agenda, however intuitively appealing or convincingly located on the moral high ground. In a multi-polar, rather than bipolar world, the UN is not the institution to produce a progressive new consensus on drug policy!

As the historians of the drug policy system more than competently remind us, the multilateral conventions that govern it were negotiated by elites, and the elites in the nineteen fifties, sixties, and eighties were very much creatures of the bi-polar Cold War world. Many were barely emerging from a century or  more of brutal colonial regimes, eager to join the new post-war international order, one small price of admission among many being allegiance to a drug free world   Democratisation and vibrant civil society movements based on awareness of economic, social, and cultural rights were not the order of the day when the Single Convention was being drafted and ratified during the mid-twentieth century.  Just because they are the order of the day in many European and high income countries in this century, promoting the right to health of people who use drugs, for instance, does not mean that such civil society movements are the order of the day in countries now dominated by post-colonial elites whose survival depends on their ability to prop up neo-liberal globalisation policies run by the IFIs.

As President Cardoso rightly points out in his essay on the UNGASS, the Latin American countries struggling with the high burdens of drug market violence imposed on them by the consumption patterns of the wealthy north, were the first UN member states to reject the earlier elite consensus and lead the current call for reform.  But that is because the political histories of those countries have moved them from military dictatorships, usually US funded and trained, to civilian constitutional governments premised on electoral accountability and respect for human rights.This process of regime change and reform has taken decades, and has birthed all kinds of new foreign and domestic policies, of which a new look at drug policy is only one. 

Other UN member states, such as many in Africa, East Asia, and the Pacific, that have not undergone such seismic domestic regime changes, or have not suffered the consequences of drug market violence in the same way as the Latin American countries (“so far from God, so close to the United States” in Porfirio Diaz’ immortal words) unsurprisingly have a less sanguine view of drug policy reform and human rights.  Their foreign and domestic policies will be based on what their governing elites perceive as best for themselves, and for their countries — nothing new about that in the policy universe of international relations, so why does the drug policy reform movement even harbor what will be a disappointed expectation that “global” drug policy will change next week?

There is no longer a global drug policy consensus because what global consensus there was during the bi-polar Cold War world has dissolved into a multi-polar world characterised by many different political regimes at many different levels of political development.  The progressive, democratised, newly energised UN member states who believe they have history on their side as they reject the twentieth century drug war consensus can provide only normative and discursive leadership to the rest of the world, just as the drug warriors provided that leadership in the previous cycle. Unlike their predecessors though, the new thought leaders will be unable to impose their will on the naysayers whose political regimes exclude civil society and pay only lip service to human rights. And these regimes cannot rely on any “Great Powers” to maintain the old consensus, however fragile, since countries where civil society is now vibrant and pluralistic will no longer play ball.

The global drug policy reformers predicting next week’s disappointing outcome envision a shared cosmopolitanism based on public health, human rights, and solidarity with the marginalised, but as Emmanuel Kant, the pre-eminent philosopher of cosmopolitanism well knew, the cosmopolis can only consist of states that enjoy a republican form of government. Republican forms of government are those in which the demos, or the people, are sovereign, and keep their political representatives accountable through regular elections.  States that are oligarchies, tyrannies, or military dictatorships are structurally misaligned with the idea of Perpetual Peace, universal rights, and a categorical imperative based on autonomy and rationality. 

Those of us who want to reduce the harm of the century old drug policy regimes can work productively with member states themselves, with civil society in those states, and with regional organisations committed to the wellbeing of their populations.  This would represent constructive engagement and possibly produce a more intelligent conversation at the 2019 UNGASS, the institutional endgame set up in 1989.

Allaying fear of addiction: the main barrier to access to pain medicine in the world

Fear

As preparations begin for the United Nations General Assembly Special Session on Drugs, I address fear-driven opioid policy and calls for integrated education on pain and dependence, and improved clinical practice for both.

Fear of diversion, abuse, and addiction actively conditions the scarcity of medical opioids in most countries.

Palliative care advocates often choose to distance themselves from ‘drug policy reform’ debates about national and global efforts to control and reduce the harm of illicit drugs. Indeed, many see people who use illicit drugs as ‘the problem’ that hinders legitimate access to opioids for pain relief.

Yet the challenge of improving access to opioids for palliative care is joined at the hip with drug policy reform and law enforcement. Fear of diversion, abuse and addiction actively conditions the scarcity of medical opioids in most countries. The same fear or – more accurately – phobia, has a chilling effect on medical education and results in stigmatisation and negative public health outcomes for both palliative care patients and people who use drugs who need to access treatment.

According to the International Narcotics Control Board (INCB) survey of countries where access to controlled medicines such as morphine and methadone is low-to-inadequate, fear of addiction is the main barrier to access. The scream Munch depicts in his famous painting can be seen to aggregate the screams of the millions of people whose doctors cannot or will not prescribe morphine or other painkillers because decades of fear have configured systems of law, education, medicine and culture, wherein fear of diversion, ‘abuse’ and addiction trump the ethical duty to relieve avoidable pain and suffering.

The fear-driven paradigm deprives more than 80% of the world’s population (5.6 billion out of 7 billion) of access to opioid medicines for pain, palliative care and dependency treatment. These people literally pay the price of this socially and politically generated fear with their lives, the quality of their lives, and their families’ and communities’ copathetic pain and suffering.

This fear-based approach to pain relieving medicines derived from ‘narcotic drugs’ – read opium poppies that have been used as medicine for millennia – is based on the 19th and early 20th century experience of European and US missionaries in China and the Far East who witnessed the deliberately induced ‘epidemic’ of dependence created or supported by their own governments (Great Britain and the US for the most part). Opinion leaders feared that the corrupting effect of ‘oriental’ opium ‘addiction’ would spread to the respectable middle classes in their home countries. There is a prolific literature on this, and many primary sources are archived at the World Council of Churches Ecumenical Centre in Geneva, where I have spent many happy hours of research.

But that was then, when there was no evidence-based addiction medicine as we know it today. Concepts such as ‘prevention’, ‘treatment’, ‘tolerance’, or the titration that is intrinsic to palliative care were unknown. Any and all use was stigmatised as ‘addiction’. That day and age was pre-HIV/AIDS, pre-injection drug use, and pre-palliative medicine. The only remedy at hand, to the social reformers who wanted to abolish the scourge, or ‘evil’ of addiction as they called it – since it hampered their missionary activities in the far reaches of the Empire – was what is now known as ‘supply control’. Supply control means literally eliminating all sources of narcotic drugs on the planet, except for the amount needed (an imaginary number in the early 20th century) “for medical and scientific purposes.” Resulting policies generated the model of forced crop eradication, punishment, and military policing that is popularly known as ‘the war on drugs’, creating large black markets, violent trafficking cartels, overflowing prisons and so on.

Three decades after the international treaty regulating narcotics was drawn up at the United Nations, we have relatively accurate data: The World Drug Report, published every year by the United Nations Office on Drugs and Crime (UNODC) estimates the number of people who have used an illicit drug in the past year is 243 million. The number of ‘problem drug users’, people who need opioid dependence treatment, is estimated at (an annually stable) 27 million, out of a world population of more than 7 billion. And globally, the number of people needing treatment for dependence disorder relative to availability mirrors the unmet need for palliative care: at least one in ten.

There is no need to fear the prospect of generalised dependence disorder as did previous generations. There is wide-ranging agreement about what causes it, how to identify it, and how to prevent it. However, the policies are severely lacking. We now know how to alleviate severe pain and symptoms resulting from cancer, terminal AIDS and other disorders. Again, appropriate policy lags behind palliative medicine’s rapid development as a recognised specialty. Morphine is cheap, easy to produce, and scarce. Yet countries like Uganda and Indian states like Kerala manage to subsidise it and teach their pharmacists to reconstitute morphine powder for the needs of their citizens.

Institutionalizing palliative care knowledge and practices more widely, alongside evidence-based prevention and dependency treatment, will dissipate and displace the fear generated by the old paradigm of the ‘evils of addiction’. Expanding clinical education about pain and dependence, and integrating both practices into primary healthcare are pragmatic first steps.

The new paradigm of global palliative care is responding to fear by demanding appropriate national and international institutions. You don’t have to be a Christian to subscribe to the notion that “God hath not given us the spirit of fear; but of power, and of love, and of a sound mind” (2 Timothy 1:7). You can be a humanist, an atheist, even an evolutionist to help midwife this new paradigm into being so long as you can synthesize love with a sound mind and good clinical skills.

Drug Policy, Faith and Vulnerability: Salt and Light

A meditation on drug policy and the Word: security, vulnerability, and light. 

Katherine Irene Pettus, PhD 

If you remove from your midst / oppression… then light shall rise for you in the darkness, / and the gloom shall become for you like midday.

 Isaiah 58:7-10

I came to you in weakness and fear and much trembling, and my message and my proclamation were not with persuasive words of wisdom, but with a demonstration of Spirit and power, so that your faith might rest not on human wisdom but on the power of God.

I. Corinthians 2:1-5

Much of the talk about “drug policy” in local, national, and international circles I move in focuses on the concept of “security” and indeed, much of drug policy is now “securitized” – meaning that politicians connect the threat of “drugs” with threats to national security, combating it with increased law enforcement funding and intelligence services.  The rationale is that drugs not only threaten individual and public health, but that trafficking and money laundering destabilize good governance, sustainable development, human rights, etc.

There is no doubt that many individuals, families, and communities experience the very negative and often tragic effects of illegal drug use and trafficking. My family is only one of the millions suffering the effects of prohibition and mass incarceration.  The question, though, is whether it is “drugs” themselves – the plants and pharmaceutical preparations that cause narcotic effects, that are the problem, or the fact that they are illegal and therefore unregulated. By definition, their illegality puts the drug economy in the hands of criminals and international criminal networks. People who use drugs, whether for pleasure, because they are “dependent,” or are “addicted” must then also participate in criminal networks, often at the cost of their health and their lives.

What on earth, or in heaven’s name, you might be wondering, might this have to do with faith, or with religion, or even today’s readings?  A lot.  The oppression Isaiah names, which must be removed, is the illegality and stigma that accompanies drug use.  That oppression brands people who use drugs as outsiders, as separate, or unholy, and is reminiscent of the illegality, ostracism, and repulsion that branded the lepers and “demoniacs” Jesus healed from his compassion.  Purity laws, whether Talmudic, Christian, or secular (in the form of drug prohibition) by definition separate people considered ‘unclean’ from the body of Christ and the Kingdom.  Jesus very intentionally turned those laws upside down when he touched the ‘impure’: bleeding women and sex workers, paraplegics, schizophrenics, the dying, and even the dead.  It seems self evident that, as Isaiah said, and Jesus demonstrated, removing oppression from our midst brings light.

Paul’s disarming admission of weakness, which he (counter) intuitively understands as Power, combines two apparent opposites that generate the paradoxical resource of vulnerability. This universal, incredibly uncomfortable, aspect of the human condition, makes us shriek as infants, and use substances or activities (alcohol, coffee, tobacco, sex, shopping, or narcotics] as young people and adults. Paul’s letter puts us on notice that our search for the (individual or collective) security that temporarily offsets our vulnerability is futile. As one who oppressed the vulnerable himself – Saul, Saul why do you persecute me? –would have rung in his ears through his dying moments, Paul learned at a molecular level on the road to Damascus that the current of Power only flows through the fabric of utter defenselessness.

Jesus tells the disciples that we are the salt of the earth and the light of the world, a light that must not be hidden. Apparently speaking in riddles, he asks what salt can be seasoned with once it loses its taste.  His/our vulnerability is our saltiness: even our tears are salty, and the moment we try to armor ourselves against the “weakness, fear, and much trembling” Paul describes, by scapegoating and sacrificing others, we lose our savor and dim our inherent and collective radiance.   Societies that support rather than punish vulnerable people who use drugs are more resilient and have better public heeclipsealth outcomes than those that try to stamp them out in the futile effort to create a “drug free society”.

The apparent power of the state (us) to criminalize drug use only empowers traffickers, police, and prison guards. Admitting and sharing our individual and collective defenselessness in the face of our very human desire to alter our consciousness, paradoxically returns to us the power to remove oppression, casting a very different light on the “drug problem” and allowing us to begin resolving it together, in the parliament of the Kingdom that admits of no outsiders.

Katherine Pettus, PhD is an independent scholar and consultant who represents the International Association for Hospice and Palliative Care as an NGO at the Commission on Narcotic Drugs in Vienna.  She is also a convert to the Roman Catholic faith and a member of the English community of Sacred Heart church in Budapest.