Written by Rachel Knox, M.D., M.B.A.
MAPS Bulletin Winter 2021: Vol. 31, No. 1
As we embark into 2021, we find ourselves at an inflection point of global proportion. People are sicker and more distressed than ever, but there is a silver lining, a glimmer of momentous hope. Significant healing is within reach, but only if we get this one thing right: health equity in drug policy reform.
The impetus behind certain interests in cannabis and psilocybin legalization and regulation is what concerns me most. On one hand, COVID-19’s acute toll on the economy has resulted in serious considerations for cannabis legalization. On the other hand, governments and other stakeholders have long recognized the economic impacts of both the suppression and legalization of these entheogens. Whichever the case, we must ensure that both legalization and regulation, wherever and whenever they happen, recompense the people who prohibition hurts most: Black, Indigenous, and Latinx people, and patients. We can only make the necessary amends if we put their needs first.
Continue reading to explore with me the meanings of health and health equity as we navigate the intersection of ecological sustainability, the War on Drugs, drug policy reform, and psilocybin legalization.
What is health? It’s remarkable, really, how variable the definition of health seems to be. According to the World Health Organization (WHO; 1946), “health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.” With all due respect to the WHO, I disagree. Health is a state, but it is not inherently good; it’s not inherently wellness or wellbeing. Health, at any given time, be it good health or bad health, is the net of all determinants of wellbeing, and a function of sustainability.
Let’s unpack this, beginning with a comprehensive review of ecological sustainability, as understanding ecological sustainability is prerequisite to understanding health.
Total sustainability is best explained by the ecologist Robert Goodland, former Lead Specialist of the Environment Department of the World Bank. He describes sustainability as the sum of four comprehensive pillars: Economic Sustainability, Environmental Sustainability, Human Sustainability, and Social Sustainability. Goodland articulates that sustainability is not only the prevention of ecological harm, or the avoidance of depleting natural resources — it requires maintenance, and maintenance requires capital investment (Goodland, 2002.). That means making investment in human capital — in the education, skill development, knowledge, and leadership of human beings, as well as in their physical, mental, and spiritual fitness. It’s investment in environmental capital — in preserving clean water, land, air, forests, and mineral-dense soil. It’s investment in economic capital — in maintaining the value of currency and its fair distribution across a society. And it’s investment in social capital — in infrastructure and the systems required to establish and maintain the basic frameworks for society.
If any one of these pillars is lacking, the balance that is ecological sustainability becomes compromised.
State of Human Health
So what does the current state of human health suggest about our commitment to total sustainability?
One in 10 American adults is suffering from heart disease or diabetes (Center for Disease Control and Prevention [CDC], n.d.); 1 in 5 from chronic pain (Dahlhamer et al., 2018), irritable bowel syndrome (IBS), or mental illness such as anxiety, depression, or posttraumatic stress disorder (PTSD; National Alliance on Mental Health [NAMI], n.d.. One in 3 American adults is ailing from insomnia, high blood pressure, or pre-diabetes (University of Pennsylvania School of Medicine, 2018; CDC, n.d.); 2 in 5 will develop cancer (American Cancer Society, 2020); 1 in 2 suffer from chronic headaches (WHO, 2016); and 1 in 1.5 are managing some form of chronic stress (American Psychological Association [APA], 2017).
These conditions are a result of human injury caused by poor diets, chronic prescription drug use, isolation, and emotional stress. They are the result of environmental injury caused by chemical pollution, habitat destruction, deforestation, depletion of non-renewables, and overharvesting renewables. They are the result of economic injury caused by soaring debts, predatory economics, and brutal capitalism. And they are the result of social injury caused by selective investment and disinvestment; systemic and institutional racism and classism; and inequitable policies, regulations, and distribution of resources and services.
Our leading causes of disease reflect an ecological problem in that they are caused by the products, services, and circumstances that our industrial complexes and their politics create and perpetuate as they develop more frankenfoods and drugs, more urban metropolises, and more technologies in a race against the balance of our own nature and towards profits.
The state of our health is a reflection of our ecosystem, which is really a reflection of our priorities and is inextricably tied to ecological sustainability
This all leads me to my favorite, holistic definition of health. Health is the composite state of one’s mental, physical, spiritual, and ecological wellbeing. It is also the state of community wellbeing and the state of a society’s wellbeing, and all three — the health of individuals, communities, and all of society — are functions of total sustainability.
Translated another way, optimal health is the net sum of economic, environmental, human, and social determinants. I call these the four determinants of wellbeing.
State of Black, Indigenous, Latinx Health
Now, let’s juxtapose what we know of the health of the general population against what we need to acknowledge and understand deeply about our Black community.
Adults in America’s Black community are 1.2 times more likely than white adults to die from cancer and 1.3 times more likely to be obese, a major risk factor for cancer, diabetes, heart disease, and other metabolic disorders. Black people are 1.5 times more likely to develop high blood pressure, a leading cause of heart disease and stroke; 1.6 times more likely to develop diabetes and 2.1 times more likely to die from it; and 1.2 times more likely to develop asthma and 2.8 times more likely to die from it (U.S. Department of Health and Services Office of Minority Health, n.d.).
Regarding mental health, Black adults (including those identifying as mixed-race Black) are more likely to have feelings of sadness, hopelessness, and worthlessness than white adults, while Black and mixed-race youth are more likely to attempt suicide than white youth (CDC, 2018)
This is the Minority Health Disparity Gap, and we’ve known about it for a long time (Healthy People, 2020). Healthy People 2010 and 2020 had audacious goals to close it, but COVID-19 has made it strikingly apparent that our society has not invested in the wellbeing of our Black community, nor in our Indigenous or Latinx communities , and perhaps doesn’t actually know how.
A History of Omission
American society and its leadership have a nasty habit of erasure. This is remarkably evidenced in our secular history books, which reduce the treatment of Black and Indigenous people and their experiences in America to a few chapters that cover America’s discovery and exploration, the Trail of Tears, slavery, the Underground Railroad, and the Civil Rights Movement in as few words as possible.
One of the reasons our Western, conventional medical system is failing so many patients is because medical care addresses symptomatology and rarely the source of illness. It doesn’t know how to heal people, because it ignores the root causes of disease. Similarly, we will not find our way out of racial disparity by treating its symptoms. We have to treat it at its root cause, which is all but substantially hidden within the annals of America’s history of the War on Drugs.
The War on Drugs criminalized entheogens like cannabis and psilocybe, and the irony is two-fold. First, each held significant cultural, economic, and spiritual value at one time. Cannabis was a therapeutic staple, well stocked in household medicine cabinets and prescribed liberally by medical doctors, while hemp was a highly valued American cash crop grown by enslaved Black people at the height of its production. Psilocybe, on the other hand, played a significant role in Indigenous sacraments and healing throughout North, Central, and South America. But what compounds the irony is this: Black, Indigenous, and Latinx (BIL) people were stripped of their access and knowledge by prohibition, then had their craft and practices weaponized against them through their criminalization. The disproportionate enforcement of prohibition laws in BIL communities, a process that imprisoned bread winners and heads of household, has contributed to intergenerational marginalization and disinvestment in the wellbeing of these communities, negatively impacting all 4 determinants of wellbeing.
It has been a particular degree of greed, cruelty, racism, scarcity mindset, and denial that is the root cause of ongoing health disparity.
What is Health Equity, Really?
Through systemic racism and the War on Drugs, Black, Indigenous, and Latinx people have been disproportionately denied the assurance of access to wellbeing.
Equitable access to wellbeing is what’s known as Health Equity, and it is created and maintained by the impartial and intentional distribution of attention and investment across all 4 determinants of wellbeing, such that they are optimized and balanced within and across a total population, resulting in healthy infrastructures, healthy economies, healthy environments, and healthy people, communities, and societies.
Health Equity achieves wellbeing for all people and can be measured. This also means that we can hold authorities accountable to reporting just how well our social frameworks facilitate wellbeing according to the 4 Pillars of Health Equity.
- Human Equity: the impartial optimization of individuals’ knowledge, skills, ability, capability, and adaptability; and that of their physical, mental, and spiritual fitness.
- Economic Equity: the impartial assurance of access to the possession of economic resources (income, savings, assets, capital, etc.), and personal and collective agency over the flow of these resources through a household and community.
- Environmental Equity: the impartial guarantee of the existence of, access to, and maintenance of clean air, clean water, clean land, clean soil; clean, safe, and natural outdoor spaces; and clean, safe, and consistent housing options.
- Social Equity: the impartial assurance that social infrastructures facilitate 1) fair and continual access to economic, environmental, and human resources, services, and justice; and 2) social participation, cooperation, trust, cohesion, and personal and collective productivity.
Psychedelics and Health Equity: Integrous Stewardship of Psychotropic Legalization and Regulation
So here’s the nexus. Through their prohibition, entheogens like cannabis and psilocybe (i.e., psilocybin) have been weaponized against people, and chiefly those identifying as Black, Indigenous, and Latinx, resulting in health disparity. As such, these communities should be the first to benefit from their legalization and regulation. Restitution is the reason why we should be decriminalizing, legalizing, and regulating the economies of psychotropic commodities, followed closely by their incredible medical utility for all of humanity. And this is why regulatory frameworks must be equity-centric, decolonized, and stewarded with integrity.
This is not only the social responsibility of local, state, national, and international governments. It is the responsibility of every stakeholder — every regulator, every operator, and every ancillary service provider — in the nascent cannabis and psilocybin industries to ensure that the regulatory frameworks, economies, tax structures, and utility of cannabis, psilocybe, and their derivatives serve health equity. They should be seen as the principal investment vehicles to optimize determinants of wellbeing and total sustainability in all communities, beginning with those most negatively impacted by the War on Drugs. Prohibition harmed BIL people and communities, so legalization must heal them. To argue against this is callously reductive and reprehensible, and many do (Jaeger, 2020).
Ethnobotany and Decolonization
Besides coming to terms with America’s — and, really, our global — racist history, addressing health disparity at its root cause will require a drastic “unknowing” also referred to as decolonization.
Prohibition of plant medicines, like entheogens, deprived all people of all colors from accessing natural, safe, effective, affordable, and holistic medicine. It has denied all people of life-saving therapies and experiences. And it is just as important to understand that the cultural appropriation, control, and in some cases erasure, of Indigenous craft, practices, and medicine by Western authority — i.e., the colonization of plant medicine — has deprived us all from cultivating a collective appreciation and respect for traditional knowledge and from properly honor
ing, crediting, and rewarding Indigenous people globally who originally fostered that knowledge. We all need to be freed from this debt.
One way to do this is through edifying Western, or conventional, scientific and medical standards of exploration, study, and validation with the promotion of Ethnobotany, coupled with eliminating the thinking and knowing reflective of Western perceptions of superiority over traditional and Indigenous knowledge, science, and medicine. We must eliminate the pervasive methodologies used to control, suppress, hide, adulterate, co-opt, or market Indigenous wisdom, especially for capitalistic gains.
To put this into perspective, try to imagine what it might feel like to witness the legalization, regulation, and commoditization of a plant medicine once traditional to your community, but that has since been arbitrarily denigrated, made illegal, and even used to disproportionately marginalize and criminalize you. Add to this your systemic exclusion from the economic opportunities birthed through its now-legal market, and the reality that little-to-none of the billions to trillions of dollars that its market generates get passed back to your community, the very community out of which the plant medicine originated. This is what is happening with many plants and plant medicines historically cultivated by marginalized Indegenous people all over the globe.
The stark truth is that plant medicines are being commercialized, and some legalized, for the benefit of white wellness. From who “wellness” is marketed to, to where it can be accessed, American “wellness” is primarily consumed by white Americans in predominantly white communities. From yoga to palo santo and everything in between, the commercialization of healing and “wellness” is really the commoditization of global Indigenous knowledge and wisdom, and of Indigenous science and medicine, but not to their credit nor reward.
Oregon Voted, Now Oregon Must Work
With the passage of Measure 109 in 2020, my home state of Oregon is tasked with the regulatory development of a Psilocybin Assisted Therapy program and the psilocybin industry the program will intrinsically create. The state has an opportunity and responsibility to erect both a first-of-its kind and best-in-class Psilocybin Assisted Therapy program and a psilocybin industry that are Indigenous-led, equitable and decolonizing, patient-centered, science-informed, and rooted in sensible market economics.
At a minimum, Oregon’s framework should ensure that Black, Indigenous, and Latinx people have equitable access to psilocybin therapy and that they benefit from it.
BIL people have suffered disproportionate and intergenerational psychological trauma as a result of the War on Drugs and systemic racism more broadly. In my work I have recognized this trauma as a significant barrier to BIL people’s use of cannabis as medicine for fear of continued stigma and discrimination. Given the therapeutic potential of psilocybin to treat the very trauma the War on Drugs and systemic racism have cumulatively caused, there is a duty to dismantle stigma and to treat the trauma with this breakthrough therapy. Oregon must ensure that BIL communities have 1) awareness, 2) education, 3) local access, 4) affordable therapy, 5) treatment specialists and researchers who look like them, and 6) the assurance that Oregon has an interest in monitoring, measuring, and reporting the short and long-term impact of psilocybin therapy in its BIL communities as the program evolves.
Oregon’s framework should also ensure that historically marginalized BIL healers, entrepreneurs, and workers have equitable access to economic opportunities as licensed operators throughout the entire psilocybin supply chain, from cultivation to treatment administration. Economic justice is not only a determinant of wellbeing, but wherein psilocybin is a traditional Indigenous medicine, racial justice is the assurance that the Indigenous peoples of the Americas be among the first to benefit economically from its sale and distribution. Oregon must prioritize and protect Indigenous influence and participation in its psilocybin market.
If healing is what we’re after, and if we believe that entheogens such as cannabis and psilocybin are our gateways to health, wellbeing, and inspired living, we must steward their decriminalization, legalization, and regulation integrously. We must guarantee that the programs and markets these processes create lead to impactful and measurable pathways to actuating health equity across all communities, beginning with those most harmed by the War on Drugs. It is the nature of these entheogens to integrate and to heal. Let us follow their lead; it’s our entheogenic duty.
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Dr. Rachel Knox, M.D., M.B.A., is a certified Cannabinoid Medicine specialist and Clinical Endocannabinologist with a background in Family, Integrative, and Functional Medicine. Along with her family she founded Doctors Knox, Inc., the American Cannabinoid Clinics, and ADVENT Academy. Dr. Knox is a policy and regulatory consultant on cannabis health equity, and her commitment to reform extends into educating communities of color about the role cannabis can play in addressing the Minority Health Disparity Gap, and the broader way cannabis can impact the total wellbeing of these communities through creating health equity. Dr. Knox is Chair of the Oregon Cannabis Commission, member of Portland’s Cannabis Policy Oversight Team, Board Member for Doctors for Cannabis Regulation, Board Member of Minority Cannabis Business Association, Advisory Board Member of the American Academy of Cannabinoid Medicine, Co-founder and President of the Cannabis Health Equity Movement, and Board Member for Nuleaf Project PDX.