Afghanistan, the war on terror and the war on drugs

Watching scenes from Kabul airport recently felt like déjà vu for me. The Vietnam War ended in eerily similar scenes. I’ve been astonished to read more than one article that has described the events in Afghanistan as an unprecedented military defeat for the USA, or as a sign that the era of neoliberal intervention in foreign countries was over. If the USA did not learn anything from Vietnam, why would we assume it will this time when facts and evidence are even less valued than in the past. Several commentators have noted the intersection of the US war on terror and the war on drugs in Afghanistan. I have been engaged for nearly 20 years now in work to update global estimates of conflict deaths and global estimates of deaths attributable to drug use. I was curious to look a little more closely at relevant statistics.

Alfred McCoy has documented the role of opium production in the Afghanistan wars in his 2015 book In the Shadows of the American Century (see also how-the-heroin-trade-explains-the-us-uk-failure-in-afghanistan). After 20 years, the fighting (mostly) has ended, but western intervention has resulted in Afghanistan becoming the world’s first true narco-state. Opium harvesting along with US support sustained the Afghan resistance to the Soviet occupation in the 1980s, and the rise to power of the Taliban in the 1990s. In July 2000, the Taliban ordered a ban on all opium cultivation, and opium production fell by 94%. When the US invaded Afghanistan in 1991, they allied with the Northern warlords who had been active in the drug trade and smuggling. Opium production resumed and grew over the following two decades.

The UN Office on Drugs and Crime reported in its World Drug Report 2021 that Afghanistan reported a 37 per cent increase in the amount of land used for illicit cultivation of opium poppy during 2020 compared with the previous year. It was the third highest figure ever recorded in the coun- try and accounted for 85 per cent of the global total of opium production  in 2020. The increase follows a trend that has seen the global area  under opium poppy cultivation rise over the past two decades, particularly after 2009. In 2020, 43% of arable land in Afghanistan was under poppy cultivation. This was somewhat lower than the 60% peak in 2017. An estimated 95% of heroin in Europe comes from Afghanistan. Only a small proportion of heroin in the USA comes from Afghanistan, the majority comes from Mexico.

However, the US-led war on drugs with its attendant prohibition and criminalization keeps heroin prices and profits high, so that poppy cultivation remains far more profitable than other crops, and has played a significant role in funding both sides of the Afghan conflict. Narcotics are likely to have provided the Taliban with over half its revenues through organising cultivation, protecting harvests, and securing criminal supply routes into central Asia. Its military victory may now see a further expansion of the opiate economy. But what of the impact on the USA, where pharmaceutical and other synthetic opioids, particularly fentanyl have fueled an exponential increase in drug overdose deaths.

The CDC has recently released provisional estimates of US drug overdose deaths in 2020, and I have done a quick update of previous time series estimates for US opioid and other drug overdose deaths. The results are shown in the following plot. Dug overdose deaths (grey curve) have been rising exponentially for over three decades at an average annual growth rate of 10.4% (dotted grey curve) with a 29% jump in the pandemic year 2020 to 96,000 overdose deaths, of which 70,470 were due to opioids. Fentanyl and other synthetic opioids were responsible for most of these, heroin in 2020 was responsible for only around 15,400 deaths.

I have also done an approximate projection of total deaths attributable to drug use (yellow curve), which include overdose deaths, road injuries and suicide, as well as HIV and hepatitis B and C deaths associated with transmission through injecting drug use. The total attributable deaths in 2020 were estimated at around 140,000.

How does the mortality toll from the war on drugs compare with the deaths due to the Afghan conflict? Conflict death estimates for Afghanistan are hugely uncertain. Wikipedia has a review of various estimates for the Soviet war period of the 1980s, with 1.2 million deaths being a mid-range estimate. The post-Soviet period of civil war in the 1990s probably results in around another half million deaths. For the period from 2001, when the US commenced action against the Taliban and Al-Quaeda, to the end of US involvement in August 2021, I have updated earlier conflict death estimates prepared for WHO and UNICEF (see here for details) to include new data from ACLED, the Armed Conflict Location and Event Data Project. I have again drawn on the latest data from ACLED up to end of July 2021 to update estimates of total conflict deaths in Afghanistan from 1985 to 2021. For the years 2001 to 2021 inclusive, there were an estimated total of 483,800 conflict deaths.

A very approximate apportioning of this almost half a million deaths suggests that there were around 116,000 Afghan soldiers and police deaths, 51,000 Taliban fighter deaths and around 300,000 civilian deaths. Almost 2,500 US soldiers died, along with 1209 deaths among US allies (UK, Australia, Canada and EU forces), and almost 4,000 US civilian contractors.

These figures for deaths due to the Afghan war and for US drug-related deaths dwarf the current US total of just over 640,000 Covid-19 deaths to date, though of course these are concentrated into a much shorter period of one and a half years.

Although I initially thought there may be a quite direct link between the massive increase in opium production in Afghanistan and the US drug epidemic, in fact the links are somewhat more indirect. The overall US-led war on drugs leads directly to the criminal control of prohibited drugs and the complete lack of standards for drug purity and concentration (thus leading for many more overdose deaths than if they were regulated) and also to the massive profits and corruption that have sustained the Afghan poppy industry and the illicit drug trade. Last year the Taliban raised total revenues of $US1.6 billion according to a leaked report written by Mullah Yaqoob, son of the late Taliban spiritual leader Mullah Mohammad Omar, mainly through trafficking opium and heroin.

The other indirect link is the failure of both of these wars, in part because evidence and evidence-based interventions are completely subordinated to corruption, vested interest, and politics in US public policy. So-called “defence industry” stocks outperformed the US stock market overall by 58% during the war in Afghanistan. The Intercept has calculated that if you purchased $10,000 of stock evenly divided among America’s top five defence contractors on September 18, 2001 — the day President George W. Bush signed the Authorization for Use of Military Force in Afghanistan — and faithfully reinvested all dividends, it would now be worth $97,295.

Was the war in Afghanistan a failure? Not for the top five US defence contractors and their shareholders, and all the politicians that they provide funding to.

Was the war on drugs a failure?  Not for Purdue Pharma and other big pharmaceutical companies,  the Taliban, the CIA, the various cartels and organized crime involved in the illicit drug trade, or the many corrupt politicians and law enforcement personnel. Or for the white supremacists of Florida and elsewhere who were able to imprison African Americans at a substantially higher rate than whites and consequently as felons remove their right to vote.

Why do Americans die earlier than Europeans?

A recent paper by demographers Sam Preston and Yana Vierboom showed that there are an additional 400,000 deaths in the USA in 2017 that would not have occurred it the USA experienced European death rates. That is about 12% of all American deaths and higher than the COVID-19 death toll of around  380,000 in 2020.  In a Guardian article earlier this month they identified major factors contributing to this US “mortality penalty” including overweight and obesity, drug overdose, lack of health insurance, suicide, lack of gun control and racism. These deaths tend to occur at younger ages than Covid deaths on average, so that total potential years of life lost are three times greater for the excess deaths than for Covid in 2020 (13 million versus 4.4 million).

Preston and Vierboom used data from the Human Mortality Database (HMD) for their analysis. They calculated death rates based on the five largest European countries, whose combined population size is very similar to that of the United States: Germany, England and Wales, France, Italy, and Spain. They also argued that using these larger European countries  to provide a mortality standard would avoid unrealistic expectations that might result from comparisons including small countries with possibly exceptional combinations of factors affecting mortality (e.g., climate, diet, social history, and healthcare delivery).

A few days ago, I downloaded updated data from the HMD and replicated and extended their analysis to include years up to and including 2020, drawing on recent data from Eurostat and national health statistics agencies (see here for details of data, sources and methods).

The figure above shows the ratio of US death rates to the average death rates for the five European countries (the “European standard”) by age, in 2000, 2010, 2019 and 2020. US mortality rates are consistently higher than the European standard for all ages below 80 years and the ratio has gotten progressively worse throughout the 21st century. The peak ratio for 25-29 year olds corresponds to death rates for US 25-29 year olds that are three times higher than those of the European standard.

The next figure shows the annual trend in total excess deaths in the USA above the number than would have occurred if the US population had been subject to the age-sex specific death rates of the European standard. This excess rose from 219,000 in the year 2000 to 410,000 in 2019 and 616,000 in 2020. Although there were over 380,000 Covid deaths in the USA in 2020, the European standard also includes substantial numbers of Covid deaths, and the Covid excess for the USA is “only” 136,000 deaths.

I next estimated the contribution of various factors to the US excess death rate using information on cause-specific deaths and death attributable to selected risk factors in Europe and the USA. I also made estimates of the excess deaths associated with lack of health insurance or under-insurance in the USA compared to Europe where all the countries have universal health insurance, based on a study of the death rates in the non-insured in the USA. Together, the six factors identified in the following graph account for around 80% of excess deaths in the USA. 

For 2020, the leading cause of excess deaths was overweight and obesity (around 154,000 deaths), followed by Covid-19 (136,000 deaths), drug use and overdose (103,000 deaths) and lack of health insurance (74,000 deaths). Excess deaths due to homicide and suicide were smaller at 20,200 and 11,200 respectively. If the USA had the European standard death rates for gun homicides and gun suicides, it would have 15,900 fewer gun homicides and 19,200 fewer gun suicides. Around 40% of the latter would still commit suicide by other means. The figure also illustrates the dramatic rise in drug overdose deaths, the vast majority due to opioids both prescription and illicit, which has occurred over the last decade. In a previous post, I examined this in more detail and noted that, in 2019, the USA accounted for an astonishing 40% of estimated global drug deaths.

Why does the US perform so poorly in these areas? Preston and Vierboom argue that a lack of federal oversight and regulation, powerful lobbying structures, deindustrialization of American jobs, and systemic racism combine to create “an annual tsunami” of excess deaths. And that is even without the complete mishandling of the response to Covid by the Trump administration and many state governments.

A pandemic out of control

Over the last two days, I’ve been assessing the coronavirus situation across the world. I’ve posted a regional analysis of trends in new cases on my professional site (an-out-of-control-pandemic-in-most-world-regions).

I reproduce a graph of regional trends below. The dramatic difference in trajectories for Western Europe and the Americas is obvious. While levels are lower in most developing regions, this is mostly due to much lower levels of testing. But confirmed new cases in all regions apart from Europe and East Asia and Pacific are rising.

North America has the most out-of-control epidemic, and that is all due to the USA. I plotted trends for blue and red states in the USA. There is a dramatic difference, with most of the recent rise in new cases occurring in red states (that voted for Republican presidents in most of the recent presidential elections). In the week ending July 5, there were an average 226 new cases per 1 million population in red states compared to 88 per million in blue states.

In a second post which-countries-are-succeeding-and-not-succeeding, I have shown country-specific plots for selected examples of three groups of countries: (1) those that are beating Covid-19, (2) those that are nearly there, and  (3) those that need to take action.  The experiences of the first two groups of countries show that (a) it is important to act early, not wait till there a hundreds of deaths in the country, (b) it only takes about 5-7 weeks of strong interventions to get rid of the majority of cases and (c) half measures don’t work.