Crack in Brazil: a public health emergency



Francisco I. Bastos

Instituto de Comunicação e Informação Científica e Tecnológica em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. francisco.inacio.bastos@hotmail.com



Although the true size of the problem is unknown (and would require measurement by empirical studies), crack traffic and consumption have reached relevant proportions in Brazil, whether from society's perspective or based on the government's response. Unlike the U.S. history of temperance and the prohibition of manufacture, sale, and consumption of alcoholic beverages under the Eighteenth Amendment (1919), there is no parallel in Brazilian history for the recent implementation of a comprehensive plan for dealing with crack. This unprecedented situation is partially due to the fact that crack is particularly fast-acting and is frequently associated with abuse and addiction, especially affecting young people (including children and adolescents) and with unparalleled visibility as a public scene for sale and consumption, spilling out of the poor communities and occupying new urban spaces, adjacent to areas where the middle class and mass media circulate.

Yet an emergency involves not only the urgency of responding, but also the process of emerging or surfacing. In this sense an emergent phenomenon in public health requires proposing and utilizing new concepts and analytical methods. The latter exist, but they have only been applied recently. By way of example, the excellent series from 2001 with the subtitle Methods to Quantify and Understand Hidden Processes (Modeling Drug Use, EMCDDA Monograph Series 6) does not contemplate the methods used today in Brazil and the world to estimate difficult-to-access populations: respondent-driven sampling, time-location sampling and its refinements (PLoS One 2012; 7(4):e34104), and network scale-up (NSU) (Am J Epidemiol 2011; 174:1190-6). We are thus dealing with profound paradigm shifts in the epidemiology and ethnography of drug use scenes (on this point, note that the NSU formulators are anthropologists; http://nersp.osg.ufl.edu/~ufruss/scale-up.htm).

Beyond the methodological challenges for adequately grasping and measuring the issue, public policy analysis has been dangerously simplified by the lack of contextualization of drug policies as a global phenomenon (although with contrasting local expressions), governed by treaties ratified by UN member countries, which to a major extent define the national states' narrow maneuvering room. Thus, when the disharmonious and counterproductive impact of Brazilian policies is discussed (for example, when action by community-based health workers is blocked by criminal factions and police forces in a given community), one overlooks the contradictions and impasses experienced by drug policies at the international level and the crisis in the public security arena and the human rights violations in countries like Mexico and Guatemala. Finally, the debate on treatment options focuses alternately on the inscrutable nature of formations of the unconscious and formulations by different religious denominations, overlooking the milestones of the Republic and democracy, and thus the fact that critical dialogue with reason is not a luxury, but a Republican necessity. Whatever the determinants of psychoactive substance abuse and addiction, the state and society have the right and duty to submit public policies and therapeutic options to the scrutiny of empirical research and critical reflection.

Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br