The CRACK Program : Discriminatory, Unethical, Ineffective and Bad Public
Founded in 1997, Children Requiring a Caring Kommunity (CRACK), a private nonprofit organization, offers a $200 cash incentive to people who are addicted to drugs or alcohol to persuade them to undergo sterilization or get long-acting contraceptive methods such as hormone injections, implants or IUDs. There are CRACK chapters in at least nine states and the District of Columbia.
The CRACK strategy targets communities of color and low-income people, rather than addressing the problem of drug and alcohol addiction as it occurs in this country across class and race lines.
Targeting communities of color
CRACK proponents have denied the accusation that the program is racist, but their strategy reveals the program's true nature. CRACK program coordinators have directed their outreach to communities of color, ignoring drug and alcohol addiction in other communities. By placing billboards and transportation ads in locations where they will be seen primarily by people of color and by conducting ride-along's with police in neighborhoods that are majority of color, CRACK has pursued a racially discriminatory strategy.
Just like sentencing disparities between crack cocaine and powder cocaine demonstrate racial bias, the name of the CRACK program, itself, demonstrates its race-based roots. By naming the program CRACK rather than DRUNK, for example, its founder focused the program on users of crack cocaine, a problem that is more wide-spread in communities of color, and not on drug and alcohol use more broadly in spite of the fact that alcohol use during pregnancy is known to cause more serious and lasting health problems. (Streissguth AP, Sampson PD, Barr HM. Neurobehavioral dose-response effects of prenatal alcohol exposure in humans from infancy to adulthood. Annals of the New York Academy of Science 1989;562:145-158.)
A program based on a financial incentive of this size is clearly intended to appeal to poor communities. Even conservative columnist and CRACK supporter George Will has acknowledged the obvious reality that the offer of $200 is unlikely to motivate middle class and wealthy women (Washington Post, October 31, 1999). This is simply another example of an attempt to use economic need to manipulate the behavior of low-income people.
The CRACK program represents a misguided approach to the problem of drug and alcohol addiction.
Drug and alcohol addiction among pregnant and parenting women
Addiction is a treatable disease, but resources devoted to drug and alcohol treatment for women are inadequate. Moreover, addicted pregnant women who seek treatment are often turned away from programs because they are pregnant. Waiting lists are impossibly long, and budgets for treatment programs designed for women have been targeted for cuts. The federal Substance Abuse and Mental Health Services Administration, which funds 40 percent of treatment services, has reduced funding for programs for women by almost 40 percent since 1994. And federal funding for treatment programs for pregnant and postpartum women and their children is now less than 10 percent of what was available in 1995. (Drug Strategies, 1998. Keeping Score. Women and Drugs: Looking at the Federal Drug Control Budget. Washington, DC, p.29)
Playing on public fears about an epidemic of so-called crack babies
Public fears about babies born to women using crack have been inflamed by false information. Children born to addicted parents do experience problems - some health-related and some related to the stigmatization that often accompanies addiction. Proponents of the CRACK program have justified its coercive and unethical approach on the grounds that it will save children and society from the greater evils caused by the allegedly large numbers of children being exposed to crack in the womb and being born with serious health and developmental problems as a result (Clarence Page, Baltimore Sun, July 29, 1999).
The facts, however, do not support these claims. First, it is important to recognize that drug-using women do not have a greater average number of children than other women. Second, carefully designed studies have established that the use of alcohol and tobacco are likely to be the primary factors in poor fetal development in pregnant cocaine users (Cocaine and Pregnancy, Phillip O. Coffin, The Lindesmith Center, 1999); and poverty appears to trump all addictions as a source of poor health and slow development for newborns and young children (Hallam Hurt, Neonatology Department, Albert Einstein Medical Center, May 2000 presentations at the Pediatric Academic Societies and the American Academy of Pediatrics.
The CRACK program is inherently coercive, unethical and may put women's lives or health at increased risk.
CRACK's Chicago director has argued that it "supports a woman's right to choice and self-determination" because women choose to participate and can do so either by getting a tubal ligation or by using one of several long-acting methods of contraception. This argument does not acknowledge the coercion inherent in a program based on economic incentives that limits women's options to methods which, in addition to being either permanent or long-acting, may put their health at risk. Tubal ligation, long-acting hormonal methods, and IUDs can be safe and effective ways to prevent pregnancy for some women, but they are not appropriate methods for all women. An IUD user who has multiple partners and is exposed to sexually transmitted diseases is at increased risk for pelvic inflammatory infection, a potentially life-threatening condition (Contraceptive Technology, 1998). In her commentary on the CRACK program, Julia Scott, President of the National Black Women's Health Project, points out that "to focus solely on pregnancy prevention without acknowledgment of the seriousness of HIV/AIDS is callous and life-threatening."
Public health experts who have studied similar programs have warned against them on the grounds that in addition to being unethical, they are also ineffective.
CRACK program proponents claim that the program's goal is to reduce the number of "drug damaged children" born to addicted parents. The approach of the program, however, has been evaluated and found to be ineffective.
The CRACK program is opposed by prominent public health experts and family planning service providers who recognize that years of experience providing contraceptive services throughout the world have demonstrated that coercive programs rarely achieve their goals. The University of California, School of Public Health has published guidelines for the ethical and effective use of incentives in reproductive health programs and policies. It specifically warns against using incentives to further the use of particular contraceptive methods by limiting client choice and against offering cash bonuses to prevent pregnancy (1999). Additionally, studies have shown that women who felt pressure to select a specific method of contraception were more likely to have health problems with the method and less likely to be happy with their decision (Kols AJ, Sherman JE, Piotrow PT. "Ethical Foundations of Client-Centered Care in Family Planning," Journal of Women's Health, 1999, 8(3):303-312).
Constructive policy solutions to the problems of addiction in pregnant and parenting women.
A constructive approach to the problem of addiction among pregnant and parenting women would support programs to help addicts take control of their lives, not programs that take away their control. The programs which truly hold the potential to have a positive impact on the lives of children born to addicted parents are those which expand access to health care services for children and parents, extend supportive services such as high quality child care, and make effective addiction treatment programs available to parents.