Two events catapulted thirteen-year-old
James into the ominous embrace of a street gang: his parents'
divorce and the loss of a cherished berth on the junior high
football team in Vallejo, California. It was the beginning
of his descent into drug dealing and mayhem. "I wanted
to belong," he explains. "You know, to be one of
the guys."
Now a high school senior and
antidrug activist, James (not his real name) marvels at how
matter-of-factly he arrived at such a bad decision: "I
was pretty immature, I guess." He was not uninformed,
however. Even at thirteen, James knew it was a risky path.
He'd gotten all the right messages at home, school, and church.
His family is part of the tight-knit Filipino American community
of Vallejo, which, according to James, puts tremendous pressure
on kids to excel. Gangs and those they attract were exactly
what he was raised to shun. So James had some qualms and briefly
thought of confiding in an older sister. But the emotional
seesaw ruling his life in that bitterly unhappy period landed
the other way. Concluding that his sister would "just
lecture me," James chose the gang. To prove his merit,
he began selling marijuana to classmates. The descent began.
Fortunately, it didn't go
far, thanks to Youth Partnership, a community group in Vallejo
that is part of a national substance abuse intervention called
"Fighting Back: Community Initiatives to Reduce Demand
for Illegal Drugs and Alcohol." Launched in 1989 by The
Robert Wood Johnson Foundation, Fighting Back hoped to test
the theory that by targeting prospective users with prevention
and treatment programs, instead of simply sending police after
dealers, the seemingly insoluble problem of substance abuse
might finally be subdued. Vallejo, a blue-collar city about
thirty miles northeast of San Francisco, was one of fourteen
test sites in eleven states.
James had no idea he was part
of an experiment. He went to Youth Partnership meetings simply
to please his sister, who was a team leader. Unexpectedly,
through peer discussions about taking charge of one's life,
he found there the stability and sense of belonging he'd longed
for. "A lot of my advisers talked about integrity,"
James recalls. "Basically what that came down to was
you can't do what you are telling other people not to do."
James took this to heart.
First he stopped selling marijuana. Then he started steering
other kids who he thought were headed for trouble to Youth
Partnership. Then, under Youth Partnership's auspices, he
began writing articles for the local newspaper about the illegal
drug and underage drinking scene in Vallejo. "I never
thought anyone read them, but kids did, and they said they
agreed with me," James says. "Then my friends told
me that I was their role model, and that made me feel good."
Looking back, James considers
himself lucky to have found these community programs. "Youth
Partnership and the Fighting Back Program really changed the
direction I was going in," he says. "Basically,
they changed my life."
You can't get better testimony
than that for a substance abuse intervention. But it begs
several questions for those charged with finding effective
community-based strategies against drug and alcohol abuse,
such as the following:
- Can James's turnaround be legitimately credited to Fighting
Back, when he himself lists his sister and upbringing as
influential factors?
- How do you prove it?
- What if you can't?
Such issues of causality and proof
undergird a debate about Fighting Back that continues vociferously
even as the fourteen-year, $88 million experiment comes to
a close. The Fighting Back program set out to test a number
of theories, among them whether community coalitions are an
effective way of combating substance abuse. And, in the way
the experiment played out, questions remain about whether
such programs can be considered successful if they help some
people, such as James, but don't result in a population-wide
reduction in substance abuse.
At the national level, Fighting Back's
architects remain at odds with those responsible for evaluating
it, who concluded that the program had no measurable impact
on population use of alcohol and illegal drugs. Fighting Back
proponents argue variously that the evaluative methodology
was flawed, that it was fatally underfunded, and that it measured
the wrong things. Meanwhile, at the local level, among Fighting
Back's fourteen test communities, there remain widely divergent
views about substance abuse interventions generally and the
Fighting Back program specifically. These views are strongly
held; exasperation verging on anger colors the debate at every
level.
"Why all the heat?" mused
Steven Schroeder a few weeks before his retirement in December
2002 as president and chief executive officer of The Robert
Wood Johnson Foundation. Fighting Back wasn't his idea, but
Schroeder presided over most of its tempests. If Fighting
Back did not make an overall dent in substance abuse, does
this by itself condemn the concept of arraying community coalitions
against the problem-a fundamental tenet of the program? Many
of those who participated in the coalitions would answer,
resoundingly, "No!" As Schroeder bore witness, Fighting
Back's evaluation is only the latest in a long series of controversies
that have beset the program since its inception in 1989.
To what degree are Fighting Back's results rooted in the
Foundation's program design? How much can be laid at the
feet of what hindsight clearly reveals to have been an unrealistic
implementation strategy? How much had to do with problems
of leadership so severe that, at the national level, the
Foundation had to replace both the first evaluator and the
first program director, and only two of the fourteen sites
stayed the course with their original directors. A growing
pile of papers and analyses testifies to the search for
answers to these questions. But here's another one: Is the
untidy end of Fighting Back simply a reflection of the messy
social context of alcohol and illegal drug abuse?
Why Even Go There?
The Robert Wood Johnson Foundation
Takes on Substance Abuse
Crack cocaine was new to most Americans
in the 1980s, when the media began to chronicle its ravages
on the front pages of newspapers, on the six o'clock news,
and in graphically descriptive magazine cover stories. Crime
and violence, damaged babies, degraded lives. For those who
had reared children in the 1960s and 1970s, when marijuana
and psychedelic drugs loomed as the greatest threat, the emergence
of crack cocaine seemed ominous indeed. The result was widespread
alarm over harm to the nation's youth and a general perception
that "the drug problem" was out of control.
Enter The Robert Wood Johnson Foundation
or, rather, the board of trustees of The Robert Wood Johnson
Foundation, which surprised management and staff with a call
for action on drug abuse. Typically, ideas for new initiatives
in philanthropy come from staff members, many of whom are
hired because of scholarship or experience in fields targeted
by a particular foundation. But in 1986, when the trustees
first voiced concern over the drug problem, The Robert Wood
Johnson Foundation's primary focus was traditional health
and medicine. It had neither staff nor programmatic expertise
in substance abuse. This was the "Just Say No" era,
to use the slogan popularized by former first lady Nancy Reagan.
Embedded in the slogan were two messages reflecting the political
mood of the country: use of addictive substances is a matter
of choice; and if you choose to break laws concerning illegal
drugs or irresponsible alcohol use (driving while intoxicated,
for example), punitive consequences will result. Most substance
abuse initiatives back then originated with the federal government,
and about 70 percent supported law enforcement, as opposed
to prevention and treatment.1
Ruby Hearn, a former senior vice
president of the Foundation, and Paul Jellinek, a former vice
president, drew the assignment handed down by the trustees.
Hearn remembers being at a meeting at Meharry Medical College
in Nashville when she got a call from her boss at the Foundation.
The trustees, she said, had requested an antidrug initiative;
Hearn's assignment was to head the in-house drug abuse task
force. Separately, a task force on alcohol abuse was established.
Hearn recalls scrambling to come up to speed on the drug field
and, in the process, discovering "great confusion among
programs and research initiatives at the federal level."
"Some of these agencies didn't
even talk to one another," according to Hearn. "We
learned that some of the using population had multiple problems,
but if they had a drug problem, they had to go to one agency;
if they had an alcohol problem, they had to go to another
agency; and if they had a related health problem, they had
to go to yet another agency. People said if you could possibly
bring all of this activity under one roof, it would be a big
help."
Jellinek, who worked with Hearn on
the design of Fighting Back, found equally fragmented efforts
at the local level. "What struck me was the incredible
cloud of despair that hung over all the efforts from the White
House down to the community level," he said. "No
one knew what anyone else was doing, and nothing seemed to
be working."
Bringing things under one roof quickly
became a core tenet of Fighting Back, codified in the program's
1989 call for proposals. The Foundation envisioned a unity
of purpose in the substance abuse field that had never existed.
Essentially, it called for a truce among factions that had
been not only separate but competitive and, in some cases,
antagonistic. The Foundation expected advocates of twelve-step
recovery programs (the Alcoholics Anonymous model) to mend
fences with proponents of inpatient chemical detoxification.
Community and business leaders were expected to find common
ground with police, mental health, and public health officials.
Residents of drug-infested, crime-ridden neighborhoods were
challenged to commence a dialogue with the addicts they blamed
for their troubles.
Fighting Back's architects believed
that by getting all these people to work in concert, the demand
for alcohol and drugs could be reduced population-wide. In
other words, the disorder of the substance abuse field combined
with the public's contentious and fragmented view of alcohol
and drug abuse might be to blame for previous interventions'
poor results. Fighting Back's design reflected classic public
health thinking, albeit with an economist's twist-the notion
that reduction in demand would discourage suppliers more effectively
than police action.
The Foundation boldly declared these
challenges to the status quo, then promised to put its results
to the most rigorous scientific analysis. According to the
call for proposals, communities that participated in the experiment
would be expected to show a measurable reduction in substance
abuse that could be credited to the Foundation's innovative
strategy: coordinated community action to reduce the market
for alcohol and illegal drugs.
The Foundation laid out its strategy
and made clear that communities would have no leeway in how
they organized their community coalitions. This rigid mandate
from Princeton to fourteen disparate sites with unique social,
political, and ethnic infrastructures disappeared in a subsequent
reorganization of Fighting Back, at which time decisions on
governance were left to the participating communities. But
in 1990, the Foundation believed this was the only way to
solidify the "under one roof" approach. "To
ensure that effective coordination does occur," the call
for proposals read, "the applicant will be required to
establish" the following:
- "A citizens' task force on drug and alcohol abuse
to provide oversight, guidance, and support. The task force
should represent all groups in the community whose involvement
and commitment will be needed for the initiative to succeed:
parents, clergy, tenant groups, business and community leaders,
health professionals, school superintendents, principals,
judges, chiefs of police, elected officials, and others."
- "A community-wide consortium of all of the institutions,
organizations, and public and private agencies whose participation
is required to implement the proposed initiative, including
the news media, civic and religious organizations, schools,
businesses, major health care providers, human service agencies,
drug and alcohol treatment providers, and others. Applicants
should bear in mind that close coordination with local government
and law enforcement authorities is essential. Also, the
direct involvement of the relevant state agencies, as well
as private insurers, will be key to addressing both immediate
and long-range project financing."
How to hold these entities together was
left to the communities' wisdom, as was the specific means
to address substance abuse. In these areas, the Foundation
gave Fighting Back communities broad latitude, acknowledging
the diversity of substance abuse threats. Although Foundation
action on substance abuse had been sparked by the crack cocaine
epidemic, crack use wasn't pervasive in the United States.
In some communities, heroin was the dominant threat. In others,
it was methamphetamine. There was also variation in the populations
seen to be at risk for substance abuse, whether youth or homeless
people or a specific ethnic group. For example, one Fighting
Back site, Gallup, New Mexico, chose to make alcohol its
primary target, because of the historic toll alcohol abuse
had taken on the region's Native American population.2
So even though the Foundation mandated a single, all-inclusive
approach for the structure of community coalitions, it gave
the Fighting Back communities considerable leeway in setting
priorities and in the specific approaches to achieving the
goal of substance abuse reduction.
The carrot was potentially $3.2 million
in funding to each of the sites selected: $100,000 annually
for up to two years of planning, followed by $3 million to
achieve the desired results. In response to the call for proposals,
3 31 communities applied to participate in Fighting Back. Of
these, the Foundation, in 1990, awarded planning grants to
Charlotte, North Carolina; Columbia, South Carolina; Kansas
City, Missouri; Little Rock, Arkansas; Milwaukee, Wisconsin;
New Haven, Connecticut; Newark, New Jersey; Northwest New
Mexico (Gallup); Oakland, California; San Antonio, Texas;
San Jose, California; Santa Barbara, California; Vallejo,
California; Washington, D.C.; and Worcester, Massachusetts.
Two years later, all but San Jose received implementation
grants of $3 million each.
These communities set out to field-test the Foundation's
assumptions: that broad-based community collaboration was
possible on an issue lacking societal consensus; that ordinary
citizens would accept a public health definition of substance
abuse; that alcohol and illegal drugs are comparable ills;
and that clandestine behavior can be credibly measured.
In 1996, after a major restructuring of the program, funding
for six projects was discontinued, while the eight remaining
each got another infusion of $3 million. This second round
of funding ended in December 2002 with Fighting Back's official
close. But, according to the National Program Office, anti-drug-and-alcohol
programs initiated under Fighting Back continue in New Haven,
Charlotte, Kansas City, Milwaukee, Gallup, San Antonio,
Santa Barbara, and Vallejo.
Fighting Words
over Fighting Back
In early 2003, Leonard Saxe of Brandeis
University completed his evaluation of Fighting Back. Using
household telephone surveys, Saxe's team found no statistically
significant decrease in illegal drug and alcohol use in Fighting
Back sites as compared with demographically similar communities.
The data, according to Saxe, hold up within individual sites
as well as program-wide. The findings challenge the notion
that citizens' groups can effectively decrease the use of
drugs and alcohol across a community-the guiding principle
of Fighting Back and one that has been widely adopted by federal
and other agencies in similar initiatives. "There is
no pattern of differences that lead you to the conclusion
that these community-based coalitions are either a necessary
or sufficient condition to reduce alcohol and drug abuse,"
Saxe says.
These are fighting words to Fighting Back's
foot soldiers, many of whom insist that their communities
have been changed for the better. They point to an array of
accomplishments, including improved public dialogue and understanding
of substance abuse, coordination of previously disjointed
services, and new ventures aimed at dissuading alcohol and
drug use or at helping addicts kick their habits. And some
grantees flatly reject Saxe's results, expressing skepticism
about the accuracy of his method-phone surveys-to measure
illegal or clandestine behavior.
Both perspectives help to illuminate the dimensions of Fighting
Back, as well as the continuing debate on its merits. This
debate-whose outcome almost certainly will influence future
community-based substance abuse initiatives-revolves around
three distinct but intertwined issues: the goals of the
program, the way it was evaluated, and midcourse changes
in program direction.
The Original Goals
of the Program
The Foundation's 1989 call for proposals was explicit on performance
expectations, calling for
- A measurable and sustained reduction in the initiation
of drug and alcohol use among children and adolescents
- A reduction in drug- and alcohol-related deaths and injuries,
especially among children, adolescents, and young adults
- A decline in the prevalence of health problems related
to or exacerbated by drug and alcohol abuse
- A reduction in on-the-job problems and injuries related
to substance abuse
- A reduction in drug-related crime
Beyond these specific performance expectations,
Fighting Back had some larger goals, according to the program's
architects, Hearn and Jellinek. Hearn contends that Fighting
Back from the very beginning was an "efficacy trial,"
to test whether broad-based community efforts could make a
dent in substance abuse. Jellinek adds that its larger purpose
was to challenge public despair over substance abuse and restore
a sense of optimism to communities struggling with its consequences
and to the nation as a whole.
The Evaluation In a program surrounded by controversy, the
most contentious issue of all concerns the evaluation. Critics
argue that the evaluation was flawed in a number of key respects:
- First, it looked at the wrong things. In noting that
Fighting Back was an "efficacy" trial, Hearn says
Saxe's survey solely measured "effectiveness,"
which is something different. "We were asking, Can
it be done?" she said. "We weren't asking, Can
it be done in six different places?" Jellinek, meanwhile,
argues that the evaluation failed to capture the larger
goals of restoring optimism and confidence at the community
level. He asserts that post-Fighting Back, drug use in the
United States has gone down across the board, including
at Fighting Back test sites; public confidence has gone
up; and community coalitions built under Fighting Back continue
to address substance abuse in an integrated fashion. "So
the irony is we accomplished our goals, but the evaluation
says it didn't work," Jellinek says.
- Second, the methodology-a telephone survey-was flawed.
Critics say that it's laughable to think that people will
reveal whether they use drugs to an interviewer on the other
end of a telephone.
- Third, the survey sample was tainted. Hearn notes that
the federal Center for Substance Abuse Prevention poured
$375 million into 251 community partnerships patterned after
Fighting Back, some of them in Fighting Back communities.
With similar activities under different auspices going on
in both treatment and some comparison sites, Hearn questioned
whether the evaluation could adequately tease out Fighting
Back's influences from those of other forces in the community.
- Fourth, the evaluation was underfunded. Critics charge
that changing evaluators in midstream resulted in the loss
of roughly $4.6 million of the original $11.5 million allocated
to measure Fighting Back results. Though Saxe says he and
program officers at the Foundation pushed for additional
funding, in the end he was told to make do.
Responding to these criticisms, James Knickman,
the Foundation's vice president for research and evaluation,
characterizes the arguments as little more than Monday morning
quarterbacking. He argues that
- The call for proposals was unequivocal in stating that
measurable change in the Fighting Back communities was
the program's objective. Everyone agreed the Foundation
had to have bottom-line numbers. Moreover, he adds, for
an overall investment of $88 million, it was reasonable
to expect tangible results.
- The Foundation's program officers and Saxe signed off
on the phone survey methodology as a commonly used tool
in substance abuse research, even while acknowledging
it to be a "fallible, second-best measure."
In fact, the rates measured from the telephone survey
tracked those estimated in various national surveys using
other data collection methods, offering support for the
validity of the telephone survey methodology.
- The concern about a tainted sample doesn't hold up.
Three comparison sites were studied for each Fighting
Back site and even when "contaminated" sites
were accounted for, no program impact was detected.
- The evaluation, both initially and subsequently, was
amply funded
Changes in Program Direction
Managerial upheaval was not limited to
the evaluation. In 1996 the Foundation transferred the National
Program Office from Vanderbilt University to Join Together,
an organization at the Boston University School of Public
Health that supports community-based efforts to combat substance
abuse. David Rosenbloom, who heads Join Together, became the
national program director.
Rosenbloom immediately abandoned the governance structure
of broad-based community coalitions so explicitly laid out
in the Fighting Back call for proposals. At the same time,
he curtailed the freedom of Fighting Back communities to
pursue homegrown interventions, emphasizing the development
of services to treat and deter substance abuse. In short,
Fighting Back's operating strategy was completely revamped
halfway through the experiment. Grantees say the program's
emphasis changed dramatically under Rosenbloom, and sites
redirected their projects accordingly, abandoning efforts
that could not quickly produce measurable results. Also
at this juncture, the Foundation terminated funding for
six of the original fourteen sites.
Ideal Meets Reality:
The Experiences of Worcester, Massachusetts, and Vallejo,
California
Anyone who has participated in his or her
community-whether as church volunteer, sewer commissioner,
block cleanup captain, or PTA mom-knows how hard it is to
achieve consensus and how late the meetings can run, even
among people who share a common vision. The people reading
the Fighting Back call for proposals were veterans of such
community efforts. Some mused about the size of the conference
room they were going to need to assemble the Fighting Back
team. Others, knowing of existing conflicts within the group
defined by The Robert Wood Johnson Foundation, wondered how
consensus could ever be reached on something as polarized
as substance abuse.
Yet 331 communities applied for Fighting
Back grants. The Foundation had projected a maximum of 125
applications, based on eligibility criteria that limited the
program to midsize cities with populations between 100,000
and 250,000. According to Kay Sherwood, author of a case study
on the Fighting Back evaluation, staff members at the Foundation
took the high volume of applicants "as a sign that they
had tapped a reservoir of interest and concern at the community
level about drug use and abuse."3
Worcester, Massachusetts, and Vallejo,
California, were among the fourteen midsize cities selected
to test the Foundation's assumptions. Both communities entered
the arena of Fighting Back in 1990 buoyed by success in winning
the grants. Neither city is accustomed to national attention.
Worcester lives in the shadow of Boston, an hour's drive to
the east, and Vallejo is underdog to San Francisco, an hour's
drive to the southwest. In this modest context, landing $3.2
million from an East Coast philanthropy was front-page news.
But the two communities would end up very
differently in the anecdotal history of Fighting Back. When
Fighting Back insiders want to showcase the program's achievements,
they hold up Vallejo. For failures, they point to Worcester.
What's remarkable, however, is how similarly the people of
Vallejo and the people of Worcester articulate the lessons
they learned in field-testing the Foundation's theories.
Both communities had grappled with substance
abuse before Fighting Back came on the scene. Vallejo, a city
of 119,000 that grew up around the former navy shipyard at
Mare Island, had a long history of alcohol problems and a
growing problem with "crank," or methamphetamine,
addiction. Worcester, a manufacturing city of 173,000, was
worried about heroin, in addition to alcohol. A spike in hepatitis
B cases in Worcester in the mid-1980s, which the federal Centers
for Disease Control and Prevention attributed to addicts sharing
contaminated needles, heightened public alarm about the city's
drug problem.
But leaders in both cities said the size
of the Fighting Back grant-$3 million-was also a powerful
lure, given the bleak economic conditions at the time. National
unemployment was moving up, tax revenues were down, and municipal
budgets were under strain.
"You've got to understand how bad
that recession was and how much it affected our thinking about
the drug problem and about Fighting Back," says Lieutenant
Alexander Donoghue, a thirty-three-year veteran of the Worcester
Police Department, much of his career spent on drug-related
crime. Donoghue was an early and enthusiastic participant
in Worcester Fights Back, grateful, he says, for the prospect
of community-wide help with a problem he knew police couldn't
solve alone.
"This department had laid off fifty
officers, which it had never done in its history," Donoghue
recalls. "Teachers were being laid off. Real estate prices
were plummeting, and people were literally walking away from
income real estate that they had bought high. We had two hundred
to three hundred triple-deckers"-classic New England
wood frame housing with three apartments stacked one atop
the other-"vacant, which are like magnets to the drug
trade." He explains, "It was an ugly scene, and
here comes a chance to bring in $3 million in outside money
when our budgets were being slashed to nothing."
The lead agency on Worcester's application was the United
Way of Central Massachusetts. Eric Buch, now the organization's
president, was point man on the application. Reading the Fighting
Back call for proposals, he thought the model was "very
diverse," calling for broad-based action on a bewildering
number of fronts. But the level of detail persuaded him that
The Robert Wood Johnson Foundation had "done its homework."
"We were told that in order to make
a serious effort against a very entrenched problem we had
to show involvement in virtually every sector of the community,"
Buch recalls. "From a theoretical standpoint, it made
sense, and since we did not come from the substance abuse
field we trusted the people who designed the program."
One section of the call for proposals laid
out state-of-the-art public health methodology for ameliorating
harm, including public awareness campaigns, expanded treatment
options, and prevention education for children and youth.
Buch and others on Worcester's organizing committee thought
this made sense as well. Indeed, if Fighting Back had been
a clear-cut health initiative-say, immunizing babies against
the threat of infectious disease-results of the sort detailed
in the call for proposals likely would have been achieved.
The evil-disease-is unequivocal, and there is public consensus
that babies are worth protecting. There is also strong science
on the safety and efficacy of vaccine, as well as established
and consistent government policy to provide a framework for
effective community action.
But Fighting Back had none of these assets,
veterans of the experiment say. Federal and state policies
on substance abuse were fragmented and discordant, as Foundation
staff learned from their own research. Addiction science was
weak at the inception of Fighting Back, and the impact of
popular prevention models, such as DARE, was in dispute. Public
opinion ranged widely as to cause and responsibility for alcohol
and drug addiction, and the concept of substance abuse as
a "public health" problem was largely unknown.
It made for a very confusing conversation around the task
force table as community leaders, addiction specialists, recovering
addicts, neighborhood representatives, police, parents, politicians,
clergy, schoolteachers, and business owners struggled to find
a common language by which to identify the "evil"
and then figure out how to go after it.
Al Donoghue, the Worcester police lieutenant
who was so enthusiastic at the outset, found his interest
waning. From a regular attendee at task force meetings, he
dropped to every other meeting, then every third. "Quite
frankly, I began to feel I was out of my element," he
recalled in an interview at police headquarters. "They
had all these buzzwords, like a whole insider language."
Donoghue rummaged through his desk for an illustration, pulling
out an old report of the local project, Worcester Fights Back.
"'A longitudinal study of a cohort of sixth graders,'"
he read. "The 'disease model of drug addiction . . .'
I didn't know what the hell they were talking about after
a while."
Language and definitional disputes turned
out to be rampant in Fighting Back, even within subgroups
of the larger coalitions mandated by the program. Recovering
addicts, for example, disagree on the definition of alcohol
abuse versus alcoholism, or whether you can call yourself
"clean and sober" if you're on legitimately prescribed
medication, or whether crack is more dangerous than methamphetamine,
according to Jeannie Villarreal, a former crack addict and
Fighting Back worker in Vallejo. Villarreal's Fighting Back
assignment has been to organize recovering drug users into
mutually supportive networks that might also be forces for
community education and outreach.
"We are mostly twelve-step people;
but we are starting to get some faith-based recovering addicts,
and we are also trying to get some methadone people,"
Villarreal says. "But that's going to be controversial
because a lot of the twelve-steppers don't like the idea of
substituting one drug for another. They don't consider the
methadone users 'clean.'" The same prejudice exists,
she and others in the recovery community say, against people
with underlying psychiatric conditions whose slide into addiction
might well have been the result of self-medicating. Will recovery
support groups accept them if they are now taking psychotropic
medication? Villarreal is not sure. And this was the state
of things in Fighting Back's flagship community in late 2002.
Which is not to say that Vallejo, Worcester,
and the twelve other Fighting Back alliances failed to alter
the conversation around drugs and alcohol in their communities
or add resources that didn't exist before. They did. But none
of them were able to make their communities speak with one
voice about substance abuse. The difficulty of changing attitudes
and building consensus was underestimated not only by the
Foundation but also by Fighting Back community leaders who
tried to galvanize community action. Worcester had an immediate
marketing problem with the Foundation's decision to lump alcohol
abuse and illegal drug use under the substance abuse/public
health problem umbrella as if they were twin evils.
This was not the original concept of Fighting
Back; Foundation trustees had asked for an antidrug program.
But early in the planning process, the task forces on alcohol
and drugs were merged, according to Ruby Hearn, and discussion
began to focus on their similarities. In the culture of the
health-oriented Foundation, it was easy to see them as chronic
illnesses requiring treatment and support. There was also
clinical evidence to support this, as many drug addicts also
abuse alcohol and vice versa.
But it was also a numbers issue, according
to David Rosenbloom, Fighting Back's national program director.
Alcohol abuse is far more prevalent than illegal drug use
in the United States. Estimates, based on the definition of
abuse, range widely (the Fighting Back call for proposals
said 10 percent of Americans abuse alcohol,4 but other studies
put that number as high as 25 percent5 ). As a clandestine
activity, illegal drug use is harder to measure, but it is
generally agreed to represent a small fraction of the substance
abuse problem. So including alcohol abuse made broad-based
community action more likely.
Perhaps an early warning of the definitional confusion that
would play out in the field and of the difficulty in selling
a combined assault on illegal drugs and alcohol was the lack
of apples-to-apples comparative data in Fighting Back's call
for proposals. Only when it came to projected costs to society
was the call for proposals able to make a direct relationship
between alcohol and illegal drug use: of $229 billion expected
in 1990, $136 billion would be due to alcohol abuse, $76 billion
to illegal drug abuse, and $17 billion to intravenous drug-related
AIDS.
In Worcester, public feeling against illegal
drug use was high, but the reaction to alcohol was more equivocal.
Fighting Back workers attributed this not only to the fact
that one was illegal while the other was legal but to cultural
norms as well. For starters, business and community leaders
routinely served alcohol at fundraisers and professional gatherings.
And taverns, liquor stores, and beer wholesalers were part
of the city's business infrastructure. So while it was relatively
easy to get consensus on action against illegal drug use,
alcohol was a more complicated conversation.
"There were some attempts to lobby
the city council about liquor licenses, but they were few
and far between," says Jack Bonina, a social worker who
was on the paid staff of Worcester Fights Back. "The
drug issue was easier to get people organized around because
it brings crime, prostitution, violence, plus the medical
issues: AIDS, HIV, all of that. Alcohol is a much harder sell.
You end up looking like a fringe person railing against the
societal mainstream. This was the case not only in the corporate
community but also in the neighborhoods."
Race and class issues also interfered with
consensus in Fighting Back. Jewel Fink, a Vallejo school official,
encountered the race factor when it became her job to announce
a substance abuse prevention minigrants program for Vallejo
neighborhoods. At the time, Fink was the Vallejo City Unified
School District's liaison to the local project, the Fighting
Back Partnership.
"I knew I was in trouble when I walked
into the room and there were the white people in the front
seats, the African Americans on one side, the Filipinos on
the other side, and the Mexicans in the back," recalls
Fink, who runs the Vallejo school system's substance abuse
and pregnancy prevention programs. "I was supposed to
be running a workshop on how to apply for the grants and how
they were going to be judged on a merit basis. But the people
in the room were really stuck on this idea that they were
owed a share of the money. Then one of the Latinos in the
back stood up and said, 'Why should everyone get the same
money? Everyone knows the Filipinos are rich and the blacks
get everything, and we're the losers every time.' Basically,
he wanted more than the others got, and we hadn't even talked
about anything that the money would be used for."
For Fink, that workshop crystallized a
perspective of community that was not the Fighting Back ideal
but might be the only way to get diverse constituencies on
board. People had their own idea of what constituted community,
and edicts from the Fighting Back citizens' task force weren't
likely to change that.
Worcester also had an early experience underscoring the divisions
among constituencies that defeated collective action. The
blowup came on the very day that Worcester was celebrating
its selection as a Fighting Back city. An announcement party
was organized at Mechanics Hall, an elegant nineteenth-century
brick building on Main Street that is an iconic gathering
spot for civic celebration. Everyone who had participated
in the planning process and nearly two hundred community leaders
whose organizations had contributed letters of support were
invited to attend. "I think it was the last time all
of us ever got together happily in one room," says Donald
Chamberlayne, a Worcester Police Department crime analyst
who was the Worcester project's in-house research and data
specialist.
The meeting, Chamberlayne and others say,
kicked off with the usual celebratory speeches. Then Lois
Green, who chaired United Way of Central Massachusetts at
the time, stood to read a list of about thirty people who
would serve on the initiative's steering committee. It was
a blue- ribbon list, representing all of the municipal partners
the Fighting Back call for proposals had mandated, as well
as a cross section of community leaders. But it was weighted
toward those with the heft to push through institutional change.
A minister representing Hispanic residents in whose impoverished
neighborhoods much of the visible drug activity took place
stood to ask whether nominations to the steering committee
would be accepted from the floor. She was told no, the membership
was set. Hearing that, the minister turned and marched out
of the hall, trailed by several other Hispanic representatives.
It was a startlingly discordant moment in what should have
been a cheerful gathering. But in retrospect, says Chamberlayne,
it was a "a symbol of the rift that was never quite fixable."
The minister's action underscored perceptual
issues that would be the source of continuing tension in Fighting
Back efforts to craft action plans that could be sold community-wide.
If Fighting Back was an anti-substance abuse initiative, then
shouldn't those most burdened by substance abuse have a strong
voice in its deployment? But who was most burdened? Using
data gathered from phone surveys of Fighting Back communities,
Saxe, the program's evaluator, concluded that although visible
drug activity-manifested by drunks, drug dealers, crime-is
more prevalent in poor neighborhoods, actual drug use varies
little from neighborhood to neighborhood.6
The fact is that by taking on substance
abuse as a civic issue, Fighting Back leaders and ?eld workers
were up against attitudes heavily freighted with moral judgments,
fear, and biases that flowed from individual perception and
personal experience with drug and alcohol abuse. This made
the Foundation's labeling of substance abuse as a "public
health problem" and addiction as "chronic illness"
a particularly hard sell in neighborhoods where the detritus
of the drug trade-condoms, dirty needles-litters the sidewalks
and residents live in fear of reprisal from drug dealers.
Juan Gonzalez is a case in point. A stalwart
of Vallejo's Fighting Back project, he nevertheless flashes
anger at the notion of addicts being "sick" people
in need of help. For him, Fighting Back was literally that:
turning the tables on the drug dealers who terrorized his
family. "If it wasn't for Fighting Back, I'd probably
be in jail myself, because I was going to hurt somebody,"
he says.
Gonzalez lives with his wife and two daughters
on Coronel Avenue, a neighborhood of modest stucco homes.
An immigrant from a poor village in Mexico, Gonzalez works
double shifts as a waiter in a San Francisco hotel to provide
a safe home for his family. Coronel Avenue was such a place
until the drug dealers moved in next door.
In contrast to the Gonzalez's tidy property
with its rose beds and burbling fountain, the "drug house"
is barely visible behind overgrown shrubbery and a front yard
strewn with junk. The family's ordeal began after a beer and
drug party involving dozens of young men spilled over into
the Gonzalez yard and Juan Gonzalez stepped out to confront
them.
"They laughed in my face," Gonzalez
remembers. Soon, the parties were every-night occurrences.
Intoxicated men and women rampaged through yards up and down
the street. They urinated on the Gonzalez flower beds, dumped
beer cans and drug paraphernalia on the lawn, and on several
occasions went so far as to stand at the windows and expose
themselves to Gonzalez's young daughters.
"It wasn't just us; it was the whole
neighborhood," Gonzalez recounts. "Everyone on the
street had their tires slashed. We called them the bat boys,
because they carried baseball bats to intimidate people."
For protection, Gonzalez and his wife took to sleeping on
the floor of the kitchen, which had a window overlooking the
front yard. This lasted for more than a year. One day, a Fighting
Back representative knocked at Gonzalez's door, saying he'd
heard from police contacts that there had been drug trouble
in the neighborhood.
"I told him the whole story,"
says Gonzalez. "I told him I was calling the police five
times a day without response. I told him I was desperate and
that my girls were scared. He sent a letter to Lieutenant
[Reginald] Garcia"-the police department liaison to Fighting
Back-"and Lieutenant Garcia came over to see me."
It was the beginning of a coordinated effort with the police
department to restore a sense of safety to the neighborhood.
With Fighting Back's help, residents formed neighborhood
patrols, developed cooperative relationships with police,
and learned to use city services-housing code enforcement,
for example-to discipline negligent landlords. Barbara Gaddies,
a volunteer who lives in a predominantly African American
neighborhood known as the Crest, said that these tactics,
taught by Fighting Back organizers, also helped rid her
street of drug dealers.
Restructuring
the Program
Vallejo's strategy of targeting interventions
to meet specific needs articulated by specific communities
was that city's way of reconciling the early mandates of Fighting
Back with the political realities of community action. These
realities, mirrored in feedback from other Fighting Back communities,
led to The Robert Wood Johnson Foundation's 1996 overhaul
of the program. The desired results-measurable declines in
alcohol and drug use-had not been achieved, and program staff
members argued for more time as well as for new leadership.
With Rosenbloom at the helm and a revamped field strategy
in place, the Foundation agreed to allocate $20.8 million
over five years to eight of the fourteen original test sites.7
Under Rosenbloom, Fighting Back no longer
required participating cities to maintain the broad community
task force specified in the original proposal. In a December
1996 memorandum to the renewed sites, Rosenbloom reviewed
the lessons of the experiment's first seven years: "Each
of our communities has developed its own approach and structure,
and some of them differ markedly from the original ideas about
the components of the program. Governance structures are quite
varied; some sites target only parts of the community; and
the notion of a comprehensive single community-wide system
of prevention and treatment has never been fully developed."
Rosenbloom told the sites to choose their
own form of governance. "The key here is a structure
that works for your community and for the goals you have identified,"
he wrote in the memorandum. At the same time, however, he
sharply curtailed the freedom that sites had enjoyed to pick
their own targets and intervention strategies, and narrowed
their options. Now sites were encouraged to concentrate their
efforts on alcohol or on a specific drug rather than on all
drug and alcohol problems, as in the first phase of Fighting
Back. No site would get money unless it submitted a three-year
strategic plan stating clearly "how the projects will
make measurable improvements in specific agreed-upon outcome
measures in key neighborhoods or population groups,"
Rosenbloom's memorandum stated. "Success in achieving
these outcome objectives will be required to obtain funding
for the remaining two years."
Jane Callahan, director of the Vallejo
project at the time and now director of the Community Anti-Drug
Coalition Institute, said the discipline imposed by Rosenbloom
made the difference in her community's ability to make inroads
against substance abuse.
"All of a sudden, we got clear on
what the hell Fighting Back was all about," she says.
"Before, it was just all over the map. Someone would
come to a meeting and bang the table and say we need parenting
programs, and the next week we would dutifully start a parenting
program. We thought that was what we were supposed to do:
be responsive to our constituents."
Freed from the unwieldy organizational
structure of the original program and newly empowered to tailor
programs to specific constituencies, Vallejo launched school-based
programs that, among other things, give classroom teachers
training in substance abuse issues and provide mentors to
at-risk middle school students. Vallejo Fighting Back also
helped establish the Solano County Drug Court, instituted
addiction treatment in county jails, and collaborated with
Kaiser Permanente on expanding substance abuse treatment services
to recipients of Medicaid (called "Medi-Cal" in
California). Youth Partnership, the program that helped young
James leave gang life, also came into existence during this
time, as did the Vallejo Neighborhood Revitalization program,
from which Juan Gonzalez and his family benefited.
Callahan is proud of these accomplishments but regrets the
time lost before Fighting Back found its focus. "The
fact is, we spent the first six years in trial and error,
spinning our wheels," Callahan says. "The Foundation
kept talking numerator and denominator to prove results, and
I didn't have a clue. What I wish I would have learned from
the beginning was true strategic planning."
Vallejo got a second chance to achieve
its goals, but Worcester did not. It was one of the six original
Fighting Back sites dropped from the program. Rather than
feeling slighted, Worcester reacted with relief. Project leaders
do not dispute that their effort had foundered. In part, they
blame an early project manager who played constituencies off
against one another and the local task force against national
program leaders. The manager was replaced; but hard feelings
and mistrust had set in, and subsequent managers were unable
to recover the unity of the planning phase.
"Fighting Back did a lot of damage,"
says Patsy Lewis, executive director of the Worcester Community
Action Council and a member of Worcester Fights Back's steering
committee. She regrets that the city did not have the self-confidence
to assert its own style of community initiative but instead
squandered time, money, and energy in "i-dotting and
t-crossing" to comply with Foundation mandates.
"There were connections in this city
between business and schools and communities that we could
have built on," Lewis says. "But the model imposed
on us was so rigid. We had to gather up specified elements
of the community that weren't necessarily natural allies to
this effort. The call for proposals did not allow Worcester
to be Worcester."
Jill Dagilis, city hall's delegate to the Fighting Back
coalition, concurs. "It was such a false expectation
that you could put everyone around a table and just go,"
she says. "Fighting Back was so discouraging-we haven't
wanted to work together on that scope of citywide initiative
since. People still socialize and network, but on a particular
project, they only want to work with a couple of agencies,
reverting to traditional liaisons."
Conclusion
These are some headlines that appeared as Fighting Back wrapped
up:
- "Suspicious House Fire Kills 6; Mother, Five Children
Die . . . Neighbors say fatal blaze was retaliation for
stand against drug dealing" (The Baltimore Sun, June
17, 2002).
- "Crack Is . . . Back? In Williamsburg, hipsters are
taking eighties revivalism to a whole other level"
(New York Magazine, Nov. 18, 2002).
- "Doctors to Pay Tab for New Drug Fight: Bush team
plans to double licensing fees for physicians, pharmacies
and manufacturers to combat the abuse of prescription drugs"
(The Los Angeles Times, Feb. 11, 2003, front page).
Might these suggest an answer to
Steven Schroeder's question "Why all the heat?"
The people who worked for twelve years to implement Fighting
Back's precepts would say "Yes!" More than any flaws
in program design, implementation, or evaluative methodology,
it was the arena in which The Robert Wood Johnson Foundation
chose to do battle that accounts for the intensity of feeling
at every level of Fighting Back.
The Foundation chose to define substance abuse as a chronic
illness. It then packaged Fighting Back as a public health
initiative, lumping together alcohol abuse and illegal drug
use and calling on communities to band together against these
twin ills. It sought to join the efforts of traditional players
in the substance abuse field-police, medical professionals,
and addiction specialists-with school and civic officials,
business leaders, neighborhood groups, and recovering addicts.
And it commissioned a quantitative evaluation that hewed closely
to the standards of the hard sciences.
But substance abuse is messier than that, as the people who
carried out the program quickly learned. They realized, as
the headlines remind us, that substance abuse is not just
a disease but a danger. It is also a moving target, ebbing
for a time only to return in unexpected fashion. Crack, for
example, was chiefly a scourge of poor, inner-city, and predominantly
African American neighborhoods in the 1980s. In 2002 a New
York Magazine article reported on use by mostly white, elite,
club-hopping types out for kicks.8
Defining substance abuse as a chronic illness-an area in
which the Foundation had been working for years-probably
made Fighting Back easier for the Foundation to understand
and to fund. But it couldn't be sold at the community level.
Drunk drivers were killing people. Drug dealers were terrorizing
neighborhoods. Among Fighting Back activists were people
who had lost children to drug and alcohol addiction or who
had struggled with it themselves. They knew the damaging
ripple effects on family members, coworkers, and communities.
To them, substance abuse was not simply a chronic illness
like asthma or diabetes; it was a public menace.
Lumping alcohol and illegal drugs
into a single initiative without acknowledging their social
distinctions created another problem. Medically, this makes
sense; drugs and alcohol are both addictive, and many substance
abusers have poly-addictions. But those fighting illegal drugs
and those fighting alcohol abuse were fighting different battles.
As in the tragic case of the Baltimore mother and her children,
killed in retaliation for antidrug activism, drugs raise questions
of personal safety: of gun violence, of junkies on the stoop,
of prostitutes in the alleyways. Alcohol abuse raises other
issues-brawls, drunk driving-but not (to the same extent)
the issues of violent crime and neighborhood deterioration.
All this made it difficult to hold the community coalitions
together. And they didn't hold. In the end, no Fighting Back
project was able to sustain the Foundation-prescribed task
force. All of them retreated to smaller alliances of people
joined by common interest à la Juan Gonzalez's neighborhood
improvement group. At Fighting Back's final meeting in March
2003, Bonita Grubbs of New Haven, Connecticut, called the
required task forces "window dressing" approaches
to the idea of broad-based community action, an opinion seconded
by many others.
Finally, there is the Fighting Back
evaluation, once again reflecting The Robert Wood Johnson
Foundation's hard-science orientation of the 1980s. Much has
changed since then. The Foundation has commissioned qualitative
and descriptive evaluations to better capture lessons from
its growing portfolio of social change initiatives. At Fighting
Back's inception, however, the quantitative approach to measuring
success ruled.
Most Fighting Back grantees heard the evaluation's "no
measurable impact" verdict for the first time at the
March 2003 meeting. Remarkably, for all the heat the evaluation
has generated among Fighting Back's national leaders, those
who carried out the experiment seem neither impressed nor
discouraged by the findings.
"I'm not an evaluation expert.
I'm just a member of a community who worked on this for twelve
years," said Peter MacDougall, a retired community college
president in Santa Barbara, California. "But I have to
say all these issues at the top created only mild ripples
in the local community. Once we had our plan, that was our
project and that's what we pursued. . . . Our day-to-day decision
making was really focused on what can work here and what can
we do to make it work better."
The Santa Barbara project resisted
pressure from the National Program Office to go community-wide,
focusing instead on school-age youngsters, in the belief that
they would benefit most from Fighting Back interventions.
The work continues today; Santa Barbara's is one of the Fighting
Back projects still active at the end of Robert Wood Johnson
Foundation funding. It's not surprising, given the project's
narrow focus, that community-wide reductions in substance
abuse could not be measured by the evaluation. But that in
no way diminishes Santa Barbara's sense that Fighting Back
resulted in sustainable improvements.
William Cirone, superintendent of schools in Santa Barbara
County, counts one success as getting his community "past
denial to awareness." He quipped that his schools probably
registered higher now in statistical measures of substance
abuse because of new programs to get the problem out in the
open, identify troubled students, and get them help. Jewel
Fink of the Vallejo, California, project said essentially
the same thing: because Vallejo schools now aim to get youngsters
into treatment while keeping them in school, they consistently
look worse on statistical reports than a neighboring school
district with a zero-tolerance policy.
This was the tenor of the conversation
at Fighting Back's final gathering. The accounts of triumphs
and setbacks, false starts and unexpected dividends filled
two days in a conference room, and continued after hours.
The participants talked candidly about the frustration of
working against an age-old problem that, as recent headlines
demonstrate, persists for all the reasons the nascent science
of addiction has given us: environmental factors, social pressures,
and, more recently, brain chemistry. The Fighting Back veterans
uniformly describe their experiences as two steps forward,
one step back. Quantifying success was a struggle for all
of them, except on the most idiosyncratic level. An example
is the Gallup project, which focused only on alcohol abuse
and was not part of the national evaluation. Nevertheless,
executive director Raymond Daw said his task force strove
to measure progress via a number of local indicators, one
of them being winter exposure deaths among the acutely intoxicated
on and around the Indian reservations of Northwest New Mexico.
These dropped from 270 annually to 86-a statistic that Daw
says means a great deal to the citizens who worked on education,
treatment, and prevention programs. However, Daw counts as
an equally important indicator of progress that Native Americans
now sit on municipal committees previously controlled by whites.
Is that a Fighting Back success? In a community where the
historical definition of substance abuse was "drunk Indians,"
it is indeed.
As is the rescue of young James from
the Vallejo street gang, even if the specific cause and effect
remain elusive. James was quick to credit Fighting Back at
the beginning of our conversation. But even he wrestles with
questions about why he did what he did and why things turned
out OK when they might not for someone else.
"I can't really say what it
was specifically that made me go another way," he muses
as we say good-bye. "I guess it was good my sister took
me to Youth Partnership. And we had some mentors there who
had done time at San Quentin for drug dealing; so they could
tell us what it was really like, and that was scary."
He packs up some sample posters he'd brought to our interview;
they feature the winners of an anti-drug-and-alcohol art contest
organized by James and other youth volunteers in city schools
each year.
"Whatever," he shrugs, "I'm glad I'm where
I'm at now."
