It’s been a month since Rob Ford’s death. We suspect that many people are ready to move past discussing the legacy of Toronto’s controversial former mayor. But please bear with us. We still need to talk about Rob Ford. There’s one conversation we’ve been ignoring.
Public announcements about the health of famous people can spur important and honest public discussions about issues that are frequently stigmatized or misunderstood. The “Angelina Jolie effect” describes the increased attention to the genetics of breast cancer following her New York Times article about prophylactic mastectomy. When Charlie Sheen announced that he is HIV-positive, searches related to prevention and testing exploded and media interest picked up, after years of declining coverage of HIV. The public conversation inspired by Katie Couric’s colonoscopy on live TV significantly increased the number of screening colonoscopies performed in the US.
Sadly, there was no “Rob Ford” effect when it comes to the health of people who use drugs. Toronto received international attention after Rob Ford stated that he had smoked crack cocaine but much of this was mocking or derisive. Only a few articles used his disclosure to discuss the larger health issues, but this doesn’t mean there wasn’t public interest. A Google trends search demonstrates that a rise in searches about the treatment of crack cocaine addiction were related to searches about Rob Ford – but there was no corresponding increase in media attention.
We think there are four health-related lessons that should have emerged from a public discussion about Rob Ford’s drug use. First, Ford’s experiences are a reminder that stigma and discrimination are major barriers to the effective delivery of care for people who use drugs. It is entirely legitimate to question the judgment and behaviour of Ford and all public figures. However, the use of non-stigmatizing language to talk about people who use drugs should be universal. Language frames the discourse about drug use and changes how people think about and act towards people who use drugs. For example, people are more likely to endorse punitive attitudes towards people who use drugs when the term “substance abuser” is used, rather than a person with a “substance use disorder.” Some of the reporting about Ford exploited stereotypes about drug use and some of the language used to describe him, including the term “crackhead” was highly depersonalizing and denigrating toward Ford and all people with addictions. Stigmatizing language also affects how people who use drugs feel about themselves. At one of his last interviews, Rob Ford did not want to be seen in public. “There’s going to be people that are going to call me a crackhead,” he said. “But that’s alright. I love them too.” At both an individual and public health level, finding the right words to talk about drug use and addiction and avoiding stigmatization is an essential first step towards developing a truly person-centred approach.
Second, Rob Ford’s story offers an opportunity to discuss the role of the police and the courts in responding to drug use. As Ban Ki-moon, the Secretary-General of the United Nations, has said “we must consider alternatives to criminalization and incarceration of people who use drugs and focus criminal justice efforts on those involved in supply.” Although there was considerable discussion about whether Ford would be arrested for his drug use, there was considerably less discussion about the merits of a “law and order” approach to drug use, which Ford (ironically) and his political allies endorsed. An increasing number of studies suggest that neither prohibition-based policies, harsh drug laws, heavy-handed policing, nor frequent and lengthy incarceration of people who use drugs are effective or cost effective from a public health perspective. Portugal offers a great example how decriminalization can reduce drug use, overdose deaths, and HIV transmission. The police response to Ford’s drug use should also have encouraged much more conversation about whether drug laws apply in the same way to wealthy white people, like Ford, as they do to people who are poor or from communities who are vastly over-represented in prison populations, like Indigenous Canadians.
Third, Ford’s life presents an opportunity to think about harm reduction and access to evidence-based addiction therapies. Harm reduction refers to “policies, programs and practices that aim to reduce the negative health, social and economic consequences that may ensue from the use of legal and illegal psychoactive drugs without necessarily reducing drug use.” We think it is highly likely that Ford’s wealth and status shielded him from some of the harms associated with drug use, as he would have access to sterile equipment and safe environments, and – unlike most – he was facilitated rapid access to treatment. Many other people who use drugs do not have access to such resources. There is good epidemiological evidence that needle and syringe programs reduce the risk that people who inject drugs will acquire HIV. The provision of methadone and related treatments helps people to stop using drugs. These programs are available in some areas of the country, but are not accessible to everyone. We need to expand these programs and offer additional services, such as supervised injection. We think it is unfortunate that Ford did not support such services when he was mayor.
Fourth, we lost an opportunity to shift thinking about the nature of substance use disorders and corresponding treatment. Substance use is a chronic condition for many, as Ford recognized after he finished a drug treatment program. He described how he had a “disease for a number of years.” Two points about treatment are worth emphasizing. First, there is a need to critically evaluate which addiction treatments work. Second, for many patients, the costs of enrolling in a treatment program are high and the waiting lists are often very long. We believe that there is a need to significantly increase public access to evidence-based treatment services: addiction medicine, psychosocial interventions and treatments for medical and psychiatric conditions that are often associated with addiction.
Reflecting on Ford’s life offer an opportunity for all of us to challenge pre-conceived ideas about drug use and addiction and to think critically about drug laws and policies. Perhaps the most important response to Rob Ford’s drug use was the large degree of support he received for addressing his health problems from across the political spectrum. There was prevalent, though not universal, focus on him as a person needing care rather than as an “addict” to be written off. All would benefit from figuring out how to generalize that sentiment more broadly to all people who use drugs.