Beyond the Body Count
What Scotland's drug deaths cannot tell us and why it matters.
I have written this as one sustained essay in four acts, almost like Hitchens’ The Missionary Position or Roger Scruton’s longer essays. Each part can stand alone for readers arriving midway through the series, but together they amount to a single argument.
Most commentary on Scotland’s drugs crisis argues about solutions.
This series is different.
It argues that we have forgotten how to think.
That’s a much deeper criticism.
Every August Scotland performs a peculiar national ritual. A number arrives. For forty-eight hours it dominates the news. Television presenters lower their voices by half an octave. Cabinet Secretaries emerge from government buildings looking appropriately grave. Opposition politicians demand resignations. Charities issue carefully prepared press releases expressing heartbreak while simultaneously explaining why their particular programme deserves additional funding. Experts who have not been seen since the previous August suddenly become unavoidable.
Everyone agrees the figures are shocking, something must change, more must be done.
Then, almost as quickly as it began, it ends. The cameras disappear. The press releases stop. The experts return to conferences, committees and consultations.
The dead remain dead.
If I wanted to be cynical I would describe the whole affair as political theatre. But that would be unfair. Political theatre usually ends with somebody learning their lines.
This one ends with everyone forgetting them.
For over twenty years Scotland has become progressively better at counting drug deaths. What it has not become is noticeably better at understanding them. Those two things sound similar. They are not remotely the same.
Imagine a football manager who loses thirty matches in a season. He commissions increasingly sophisticated statistics. Distance covered. Possession. Completed passes. Heat maps. Expected goals. Sprint intensity. Nutritional intake.
He can now describe his losing team with astonishing precision.
Unfortunately, they are still losing. No sensible supporter would conclude that more statistics are the missing ingredient. They would begin asking whether the manager understands why the team keeps losing.
That is where Scotland now finds itself. We possess extraordinary quantities of information about the people who die.
Their ages, sex, postcodes, deprivation scores, the drugs found in their blood, Whether they attended treatment, Whether they had mental health diagnoses, Whether they had previously overdosed, Whether they were homeless,Whether they had been in prison, Whether they lived alone.
Year after year this information is carefully assembled, published and discussed. Yet after two decades the most basic question remains stubbornly unanswered.
Why these people? Not why drug users. Not why deprived communities. Not why people with trauma. Not why Scotland. Why these particular men and women while thousands of others living remarkably similar lives somehow survived?
That question sounds obvious.
Remarkably, it has rarely been the one our research system has actually asked. Instead, Scotland has largely studied only the people who died. At first glance this seems perfectly reasonable. After all, if you want to understand drug deaths, surely you study drug deaths. Except science has a habit of being less intuitive than common sense.
Suppose I told you that ninety per cent of people killed in road accidents had eaten breakfast. The statement could be completely true. It would also be completely useless. Unless we know how many people who didn’t die had eaten breakfast, the statistic tells us absolutely nothing.
It is description masquerading as explanation.
That distinction lies at the heart of one of the most important Scottish addiction reports that almost nobody now talks about.
In 2018 Professor Keith Matthews and Dr Brian Kidd published the Suicide Information Framework Tayside, better known as SIFT. It received little public attention. It should have transformed the national conversation.
The brilliance of SIFT was not that it claimed to have discovered the causes of drug deaths. It didn’t. The brilliance lay in asking a better question. Instead of studying only the people who had died, the researchers identified living people of the same age, sex, postcode and level of deprivation who had not died.
Now the comparison became meaningful. Not simply: “Most people who died were prescribed methadone.” But: “Were they prescribed it more often than similar people who survived?” Not simply: “Many had mental health problems.” But: “More than whom?” Not simply: “They frequently attended hospital.” But: “More frequently than otherwise similar people still alive?”
That tiny change in thinking changes everything.
It is the difference between describing a problem and beginning to understand it. The report is quietly devastating in its criticism of much previous research. It argues that many of the studies informing Scottish policy were excellent at answering four questions. Who? What? Where? When?
But incredibly weak at answering the only two questions capable of changing policy.
Why?
And perhaps even more importantly...
So what?
The authors warned that descriptive reports repeatedly “overstep the data”, drawing conclusions about cause from evidence that can only demonstrate association. Without a comparison group, they argued, researchers simply cannot know whether an observed characteristic genuinely distinguishes those who die from those who survive.
Pause for a moment and consider what that means.
For years Scottish drug policy has confidently recommended interventions based upon evidence that, according to one of Scotland’s own addiction researchers, could not reliably answer the question it was being asked.
That is rather like building a bridge after carefully measuring the river while forgetting to ask whether the ground on either side is solid enough to hold it.
The measurements may all be accurate. The bridge still collapses.
Perhaps the most revealing part of the report is not what it found. It is what it refused to pretend it knew. There is a refreshing intellectual humility throughout its pages. Again and again the authors distinguish between association and causation. Again and again they remind readers that people who die are not scientific proof of why they died. Again and again they resist the temptation to transform observation into ideology.
In modern public policy, such restraint is almost radical. We have become remarkably impatient with uncertainty. Governments like certainty. Campaign groups like certainty. Journalists certainly like certainty. Unfortunately, reality rarely cooperates. The truth is that much of what we call evidence is little more than educated description.
Description has value. It identifies patterns. It generates ideas. It raises questions. What it cannot do, by itself, is tell us why something happened. The difference matters.
Because once association is mistaken for causation, policy quickly becomes theology.
Questioning it begins to resemble heresy. (I unwillingly carry the badge of chief heretic).
That, I know is exactly what happened in Scottish addiction policy. Ideas that began as plausible hypotheses gradually hardened into unquestionable truths.
Treatment saves lives. Trauma explains addiction. Retention is success. Stigma is the principal barrier. Harm reduction is self-evidently evidence-based.
Some of these statements are demonstrably true. Some are true only in part. Some remain contested. Yet they are increasingly spoken with the same certainty, muscularity and authority, as though they belonged to a single body of settled knowledge. In doing so, we risk confusing confidence with evidence, consensus with scientific understanding, and conviction with proof.
SIFT quietly suggested something deeply unfashionable. Perhaps we do not yet understand enough to be quite so certain. That is not an admission of failure. It is the beginning of science. There is another reason the report deserves rescuing from obscurity. Buried beneath its technical language lies a profoundly human insight.
People do not die because they are statistics. They die because they are people. No life can be adequately explained by a toxicology report. Or a postcode. Or a deprivation score. Or a prescribing record. Or an ICD code entered into a national database.
A person is never simply the sum of their administrative categories.
They have families. Friendships. Arguments. Faith. Regrets. Dreams. Children. Workplaces. Neighbours. Losses. Moments of courage. Moments of despair. They live within relationships long before they appear within datasets.
Perhaps that is the deepest weakness of our present conversation.
We have become exceptionally good at measuring the administrative footprint left behind by a dead citizen. We have become rather less interested in understanding the life that produced it.
Next month Scotland will once again gather around another number. It will dominate the headlines. It will provoke anger. It will provoke grief. t deserves both. But perhaps, just for once, we should resist the temptation to believe that another statistic is another piece of understanding.
It is not.
It is only another body counted.
Understanding begins somewhere else.
And that is where this series will now turn.
"Charities issue carefully prepared press releases expressing heartbreak while simultaneously explaining why their particular programme deserves additional funding."
I see that here too in Ontario.