If a patient came to my clinic and asked if it’s OK to smoke marijuana, I would explain why it’s a poor decision for their health. However, on Nov. 8, I will vote yes on Question 4 to legalize recreational marijuana in Massachusetts.
This is because I have seen a much more frightening public health crisis up close: the devastating effects of mass incarceration for drug offenses. Rising prison populations constitute a major threat to public health and I believe the costs of incarceration for patients and communities simply outweigh the dangers of marijuana.
The current discussion among medical professionals has focused largely on the direct medical harms of marijuana, including youth addiction and cognition, and select public health issues, such as drugged driving and traffic deaths. Most doctors will justifiably tell you that these effects are significant.
But I would argue that we must consider another medical issue: Working at jails across the state, I have seen that those who are arrested for drug offenses often suffer from concurrent medical and psychiatric conditions that are exacerbated by inadequate correctional health care.
This summer, I met a young man my own age — 26 — in a Boston jail. He was arrested for possession of a quantity of marijuana just above the legal limit. Despite decriminalization in Massachusetts, possession for greater than one ounce still carries a six-month sentence and two years for subsequent offenses.
He had bipolar disorder and had not received his psychiatric meds for the five days since his arrest. He suffered from chronic pain, stemming from an old gunshot wound to his abdomen, and had only received ibuprofen. When I examined him, he was spiraling into a depressive episode and in uncontrolled pain. To make matters worse, his public attorney was on vacation and he was unable to afford his bail, meaning he would be jailed for at least a few more weeks.
His case showed me that conviction rates alone are insufficient to capture the severe health and emotional effects of churning young adults through the state correctional system. Physicians and public health advocates must consider the health consequences for those impacted by drug policy at each step of the process: targeting and arrest by law enforcement, pretrial detention, imprisonment and broader community implications.
These health harms are particularly likely to affect people of color. We know that minority groups have a higher rate of arrest, prosecution and incarceration for marijuana possession. The ACLU recently found that African-Americans in Massachusetts were more than three times more likely to be arrested for pot than white people -- a ratio that's higher than the national average. Despite the decriminalization of small amounts of marijuana in 2008, this racial disparity persists.
In 2014, there were over 1,600 arrests for marijuana in Massachusetts, admittedly a significant reduction since decriminalization. Yet each of these arrests represents an encounter with law enforcement and detention for an individual. Publicly available data are sparse for how many people in Massachusetts prisons were actually convicted for marijuana. But we do know that nationwide, they number roughly 40,000. We also know that for many defendants, having prior charges for marijuana can lengthen sentencing for other crimes or account for parole violations.
Marijuana arrests are part of a larger discriminatory policing pattern that legalizing marijuana could help to counteract. A 2015 study of more than 200,000 police encounters in Boston shows that largely black and Hispanic neighborhoods face a higher rate of interrogation and “stop and frisk” than crime rates alone would predict. Some 63 percent of Boston police-civilian encounters targeted blacks, though they comprise less than a quarter of the city’s population. Recent research indicates that encounters with police are associated with higher rates of anxiety and PTSD and a significant risk of injury or death.
Boston City Council President Michelle Wu has highlighted the uneven enforcement of marijuana laws as a reason to support legalization: "It just seems ridiculous that kids at Harvard can smoke pot and have incredibly successful careers while blacks and Latinos, particularly men and boys, who are using the same substance are sent to jail," she said in August.
Beyond interactions with law enforcement, what are the health consequences for those incarcerated and their communities? To begin with, being held in jail for days to weeks before bail or court appearances can worsen underlying health conditions and contribute to new mental illness. Longer-term, incarceration for marijuana may establish a destructive lifelong cycle that harms future employment and access to public housing, Medicaid, and Pell grants for education.
Even after release from incarceration, health risks remain incredibly high. A 2007 study in the New England Journal of Medicine found that released inmates were 129 times more likely to die from drug overdose and 13 times more likely to die of any cause in the two weeks after release, compared with the general population.
Research from Yale and Michigan indicates that, within communities, mass incarceration is linked with higher rates of infant mortality, food insecurity, infectious disease and child homelessness. The Adverse Childhood Experiences study of over 10,000 adults found that growing up with a parent imprisoned was a significant predictor of premature death in adulthood.
Earlier this month, the Massachusetts Medical Society, along with 10 other physician organizations, publicly opposed Question 4. I agree with these organizations that marijuana is an unhealthy drug. Particular policy aspects of Question 4 could be strengthened.
However, physicians should not influence public opinion with a select set of facts. I have spoken with and heard from many physicians across the state who disagree with the declaration from the Massachusetts Medical Society, which did not come from a vote of its members.
There is a distinction between the advice a doctor will give their patient in the office versus the actual policy that we should support as a medical community. It is incumbent on all of us to think more broadly about social justice in caring for communities. I see a "Yes" vote on Question 4 as a way to advance racial equality not just in the criminal justice system but as an issue of public health.
Dr. Akshar Rambachan, MD, MPH, is a resident physician at Massachusetts General Hospital and Harvard Medical School.
Correction: This piece originally stated incorrectly the quantity of marijuana above which possession can carry a six-month sentence. It is one ounce. We regret the error.