Grant Makers Must Attack Substance Abuse

By STEVEN A. SCHROEDER

The abuse of tobacco, alcohol, and illegal drugs is the nation’s No. 1 preventable health problem, yet few foundations focus on it. The Robert Wood Johnson Foundation didn’t focus on it either, but during the past decade, we changed. More grant makers should too.

One reason substance abuse can’t be ignored is that it is so intertwined with the problems facing communities, including crime, prison overcrowding, highway fatalities, and low high-school graduation rates.

To be sure, remarkable progress in fighting substance abuse has occurred over the past 10 or 15 years, and scientific developments have provided more hope and greater opportunity than ever for success in reducing abuse. The number of people who use illegal drugs monthly dropped from 23.3 million in 1985 to 14.8 million in 1999, according to the latest data available. Rates of drug and tobacco use among youths are stabilizing or even declining. Arrests for driving under the influence fell 18 percent from 1990 to 1997, even as the number of licensed drivers rose 15 percent. And from 1984 to 1999, deaths from alcohol-related crashes dropped by 37 percent, despite an increase in the number of miles driven.

Even with so much progress, it has been difficult to get policymakers or the public to care about the millions who can’t stop taking drugs, or drinking and smoking at dangerous levels.

One reason that foundations and others ignore this important issue has to do with stigma — the distaste some have for working with people with addictions.

People in this country also have a defining civil-liberty, or free-choice, ethos that gives them the right to abuse themselves. And yet when people do that, we blame them for it and are less inclined to help them.

It is a real paradox that as a nation we are willing to spend lots of money to try to cure patients with diseases that have dismal prognoses, such as pancreatic cancer. Yet we dismiss substance-abuse treatment programs with higher success rates: 15 to 20 percent cured, or as high as 90 percent in the case of Vietnam veterans addicted to heroin. Somehow foundations have to help Americans overcome this double standard. Perhaps we should view the condition more like diabetes or heart failure, where keeping the symptoms under control is an acceptable goal and cure comes infrequently.

Beyond the stigma issue, a key problem facing the substance-abuse field is a dearth of good leadership, especially at the grass-roots level. We have few if any parents’ groups up in arms over youth smoking. And families devastated by drug abuse are not mobilizing for more treatment or prevention programs in the way that families devastated by mental illness joined forces in the 1980’s.

At the national level, leadership is noticeably fragmented, creating an obstacle to effective policy change. People become exceptionally invested in a particular approach and thus close-minded to others. Sporadic, unpredictable, and fragmented financial support has left “orphans” who resent others getting funds ahead of them. They have become martyrs, and it is difficult for them to shed that embattled mentality. The substance-abuse field is wracked by infighting and a sense that some players value being correct more than being successful.

The field also lacks sufficient incentives to draw in the best and brightest, and the leadership suffers from a lack of diversity. Most experts are white males.

Fostering better leadership is, in fact, an area where foundation support could prove essential. Providing grants brings not only dollars but also prestige to the field of substance-abuse prevention and treatment. That prestige would help leaders in the substance-abuse arena to gain access to other community leaders.

What’s more, by signaling that substance abuse is an important field to support, grant makers can encourage young people to consider working on the problem, embolden existing leaders, and help break down the barriers of stigma and prejudice that hamper efforts. Such support also would encourage health workers, as well as parents, teachers, ministers, and police officers, to work more aggressively to prevent youths from starting to use harmful substances and to identify those in need of treatment.

While the lack of better leadership is a formidable obstacle, another has been the power of the tobacco and alcohol industries to block policy changes and the fact that these industries deal with legal substances. These companies use sophisticated marketing to drive sales, and we all know that they play hardball with anyone who tries to get in their way.

Philanthropy needs to become just as powerful in the war on substance abuse.

Demand for treatment of substance abuse far outstrips the supply of legitimate programs. Community foundations and other local grant makers could help develop more treatment options at the local level and use their grant money and their clout to bring about speedy and substantial results.

Community foundations can also help to enforce laws about sales of tobacco and alcohol to under-age youth. They can work with schools and parents to assure that students are aware of the real facts about substance abuse, including the reality that not all their peers smoke and drink. They can work with the local news media to inform people about the magnitude of the problem of substance abuse and to combat the pervasive pessimism that nothing can be done. And they can support the stalwarts who already are working on prevention and treatment, celebrating the accomplishments of these often-invisible local heroes and heroines.

National foundations can do all that too, but in multiple sites simultaneously. They also can support research in substance abuse, particularly on topics that do not get enough money from the National Institutes of Health: how to change attitudes and behavior, what aspects of treatment are most promising, what causes people to begin abusing alcohol, drugs, or tobacco, and what transforms experimenters into addicts.

National grant makers also can work to shape substance-abuse policy, encourage the news media to educate the public, and support leaders in the substance-abuse field.

The Robert Wood Johnson Foundation has, in recent years, developed a variety of programs to combat substance abuse.

They include long-term support for innovative research and policy institutions, such as the National Center for Tobacco-Free Kids and the National Center on Addiction and Substance Abuse, at Columbia University; support for public-education efforts, including an effort to enlist the spouses of state governors to serve as spokespersons on the issue of under-age drinking; programs to integrate effective prevention and treatment approaches into the legal and medical systems; and career-development efforts through which the foundation is trying to attract new leaders to the field of substance-abuse prevention.

The challenge now for us and other grant makers will be to continue to attack substance abuse by building leadership, the scientific-knowledge base, and public and political will. Whether the initial impulse of substance abuse comes from loneliness, despair, peer pressure, curiosity, or the understandable desire to expand feelings and consciousness, too many people end up trapped with a dangerous addiction they never contemplated.

Foundations can’t deny the staggering personal and social costs of that abuse any longer.

Steven A. Schroeder is chief executive officer of the Robert Wood Johnson Foundation, in Princeton, N.J. This article was adapted from the foundation’s 2000 annual report.