The WHO cocaine report the US didn't want you to see

Update 18.06.09: This blog post has resulted in mainstream media coverage of this story in the Guardian (by Ben Goldacre and George Monbiot) and an editorial in the Vancouver Sun: Suppressed report raises questions about drug policy. It also appeared on the front page of Reddit attracting 500+ comments and pulling in 60k hits in 24 hours


The largest ever study of cocaine use around the globe was carried out in the early 90's by the UN World Health Organisation (WHO) and funded by the UN Inter-regional Crime and Justice Research Institute (UNICRI), but under pressure from the US its publication was suppressed when it became clear the report's findings were in direct conflict with the myths, stereotypes and propaganda that prop up the war on drugs (read the complete leaked report here).

In March 1995 WHO/UNICRI released a briefing kit summarising the key conclusions, as a curtain raiser to the report's imminent publication.

• "Health problem; from the use of legal substances, particularly alcohol and tobacco, are greater than health problems from cocaine use.
• Few experts describe cocaine as invariably harmful to health. Cocaine-related problems are widely perceived to be more common and more severe for intensive, high-dosage users and very rare and much less severe for occasional, low-dosage users." (pg. 1)

the coca plant

In a classic example of what happens when public health pragmatism collides with criminal justice dogma, just two months later, at the 48th World Health Assembly, the US representative to the WHO threatened to withdraw US funding for WHO research projects unless they 'would dissociate itself from the conclusions of the study' (read the relevant segment here). He said;

"The United States Government had been surprised to note that the package seemed to make a case for the positive uses of cocaine, claiming that use of the coca leaf did not lead to noticeable damage to mental or physical health, that the positive health effects of coca leaf chewing might be transferable from traditional settings to other countries and cultures, and that coca production provided financial benefits to peasants...


"... it [the US] took the view that the study on cocaine, evidence of WHO's support for harm-reduction programmes and previous WHO association with organizations that supported the legalization of drugs, indicated that its programme on substance abuse was heading in the wrong direction. The press package undermined the efforts of the international community to stamp out the illegal cultivation and production of coca, inter alia through international conventions.


"The United States Government considered that, if WHO activities relating to drugs failed to reinforce proven drug control approaches, funds for the relevant programmes should be curtailed. In view of the gravity of the matter, he asked the Director-General for an assurance that WHO would dissociate itself from the conclusions of the study and that, in substance abuse activities, an approach would not be adopted that could be used to justify the continued production of coca."

It's easy to see why the US would be so opposed to the study being published as it not only challenges a number of myths and stereotypes about cocaine use, but it is highly critical of a number of US-backed policies. The report specifically highlights the criticism that supply reduction and enforcement policies are not working and that alternatives needs to be explored;

"The largest future issue is whether international organisations, such as WHO and the United Nations Drug Control Programme, and national governments will continue to focus on supply reduction approaches such as crop destruction and substitution and law enforcement efforts in the face of mounting criticism and cynicism about the effectiveness of these approaches. Countries such as Australia, Bolivia, Canada and Colombia are now interested in examining a range of options to legalize and decriminalize the personal use and possession of cocaine and other related products. There needs to be more assessment of the adverse effects of current policies and strategies and development of innovative approaches." (pg. 30)


"The studies identified strict limitations to drug control policies which rely almost exclusively on repressive measures. Current national and local approaches which over-emphasize punitive drug control measures may actually contribute to the development of heath-related problems. An increase in the adoption of more humane, compassionate responses such as education, treatment and rehabilitation programmes is seen as a desirable counterbalance to the overreliance on law enforcement measures." (pg. 29)

The study also points out that 'anti-drug' campaigns are not necessarily effective, especially mass media campaigns based on scare tactics;

"Despite a broad range of educational and prevention approaches, most programmes do not prevent myths but perpetuate stereotypes and misinform the general public. Such programmes rely on sensationalized, exaggerated statements about cocaine which misinform about patterns of use, stigmatize users, and destroy the educator's credibility. This has given most education campaigns a naïve image and has reduced confidence in the quality and accuracy of these campaigns…" (pg. 23)

With regards to who uses cocaine, the study says,

"It is not possible to describe an "average cocaine user". An enormous variety was found in the types of people who use cocaine, the amount of drug used, the frequency of use, the duration and intensity of use, the reasons for using and any associated problems they experience.’"(pg. 1)

However it does usefully establish a continuum for use, noting that the majority of harms are accrued by the minority of users at the extreme of the continuum;

• experimental use
• occasional use
• situation-specific use
• intensive use
• compulsive/dysfunctional use

Experimental and occasional use are by far the most common types of use, and compulsive/dysfunctional is far less common." (pg. 28)

The study additionally notes - in direct conflict with the accepted drug war paradigm that all use equals abuse - that:

"occasional cocaine use does not typically lead to severe or even minor physical or social problems ... a minority of people start using cocaine or related products, use casually for a short or long period, and suffer little or no negative consequences, even after years of use. ... Use of coca leaves appears to have no negative health effects and has positive, therapeutic, sacred and social functions for indigenous Andean populations."

In addressing the rise in use, the report posits that key drivers are the drug's illicit status combined with both rising wealth (for cocaine powder) and increased poverty (for crack cocaine).

"The increasing attractiveness of cocaine in the past two decades may be related to:

• the "glamour" of illicit drug use in general;
• increased wealth allowing more people access to what they believe is the most glamorous of all illicit drugs;
• widespread poverty or social disadvantage in countries such as the USA at a time when cheap coca preparations like crack have become widely available." (pg. 14)
  

The report was never officially published and according to the WHO it does not exist, however some of the project advisors are now pushing for it to be formally published. It has only emerged into the public domain because the relevant documents were leaked and found their way into the hands of the Transnational Institute drugs and democracy programme.

The suppression of this detailed, authoritative and independent report is yet more evidence of how certain governments, most conspicuously the US, have willfully refused to develop rational drug policy based on science and evidence - and worse, when evidence emerges that challenges their political prerogatives and drug war ideologies they will resort to bullying, threats and censorship to ensure it is suppressed. This is anti-science drug war posturing of the worst kind, and can only lead to poor policy development with increased social and personal costs the inevitable result.

Transform has passed this report on to the forthcoming Home Affairs Select Committee inquiry on cocaine in the hope that it might usefully be used to inform policy discussions, albeit only at the UK level for now, and some 13 years late.

Also from Transform:

• From soft drink to hard drug; a snapshot of coca, cocaine and crack, By Mike Jay
  
  
• How cocaine markets have been hit by the financial crisis
  
  
• Transform publishes comparative cost benefit analysis of prohibition vs regulation of cocaine and heroin
  
  
• Shoveling water: War on drugs - War on people (film about coca eradication)
  
  
• It is not coca growing per se that fuels the conflict in Colombia, but the fact that cocaine is illegal

UNAIDS and NGO statements shake CND out of its stupor

Amidst the mind numbing tedium of hours of pre-prepared self-congratulatory country presentations at this year's United Nations Commission on Narcotic Drugs (which I am currently attending in Vienna) there were a few rays of light that challenged the consensus that 'everything is fine - let's continue as before'. A few of the non state participants briefly threatened to turn the thematic session in to the 'debate' it was billed as. (a more detailed commentary on the CND to follow)

There were a series of useful contributions from various NGO's (given unprecedented access to the plenary session this year) including this powerful statement from Rick Lines at IHRA, that challenged the CND to fully incorporate human rights into drug control mechanisms, with specific reference to this being the 60th anniversary of the UN universal declaration of human rights.

Below is the complete text of the contribution from the Joint United Nations Program on HIV/AIDS (with references) delivered to yesterday's plenary session by Susan Timberlake. Its pragmatic tone was particularly striking in that it followed series of desperately dry political statements, including notably from the US, that entirely failed to touch on the public health vs criminalisation debate, HIV, or the rights of users, and in the case of the US, actively spoke out against harm reduction. That UNAIDS the statement additionally came with the UN imprimatur - so was impossible for the state representatives to ignore.

Chair, distinguished representatives, ladies and gentlemen, The Joint United Nations Programme on HIV/AIDS (UNAIDS) is pleased to have this opportunity to address the Commission on Narcotic Drugs to seek your support in breaking the dangerous link between injecting drug use and the HIV epidemic. As measures to control drugs and measures to control HIV are critically intertwined, the steps governments take in drug control are likely to have significant impact on progress against HIV.

In most regions of the world, unsafe injecting drug use is a major vector of HIV transmission. It has been estimated that up to 10% of all HIV infections worldwide result from injecting drug use, up to 30% if infections in Sub-Saharan Africa are excluded. Once HIV enters a community of people who inject drugs, it can move to the rest of the population if appropriate steps are not taken.

UNODC, WHO and UNAIDS recommend a comprehensive set of measures for people who use drugs that includes the following: (1) needle and syringe programmes; (2) opioid substitution therapy; (3) voluntary HIV counselling and testing; (4) anti-retroviral therapy; (5) prevention and treatment of sexually transmitted infections; (6) condom programming; (7) targeted information, education and communication; (8) hepatitis diagnosis, treatment and vaccination; and (9) tuberculosis prevention, diagnosis and treatment. The efficacy of these interventions is supported by overwhelming evidence.

Yet in spite of the fact that we know how to address the close links between HIV infection and unsafe injecting drug use, many countries fail to provide this comprehensive set of measures to drug users, who instead continue to face discrimination and other human rights violations. In 2006, fewer than 20% of people who inject drugs received some type of HIV prevention service, with coverage of less than 10% reported in Eastern Europe and Central Asia. Even fewer have access to opioid substitution therapy, needle and syringe programmes, or anti-retroviral therapy, despite the fact that people who use drugs can achieve the same levels of adherence to treatment as other patients with HIV.

In the 3:1 ratio mentioned by Mr. Costa – where enforcement receives three times the resources that prevention and treatment receive – it is clear that many countries take an approach to drug use that focuses on criminalization while neglecting a public health response. A public health response would provide treatment to people who evidence drug dependency and illness and would employ health and social interventions, which have been shown to reduce the harms associated with drug use. Instead, legal and social barriers severely impede access to such health and social interventions. For instance, many countries criminalize possession of syringes without prescriptions and continue to classify methadone and other opioid substitutes as illegal. In many countries, imprisonment and forced treatment with ineffective methods are the primary responses to drug use, with little to nothing being done about HIV. And in some countries, imprisonment is compounded by killings, rape, unwarranted use of force, arbitrary arrests, harassment, extortion, and violation of medical privacy and confidentiality.

Chair, distinguished delegates, UNAIDS supports countries to implement a rights-based response to the HIV epidemic for two reasons: first, because it fulfills obligations under human rights law, and secondly, because it is the most effective way to address HIV. In our efforts against the epidemic, we recognize that all people, even those engaged in activities that are deemed criminal, have human rights, including people who use drugs. Even where drug use is criminalized, people who use drugs have the rights to be free from violence and murder, to benefit from full due process before the law, to be free from discrimination and any forced treatment that violates medical ethics, and to receive comprehensive and voluntary health and social services of good quality, including for drug-related illness and for infections, such as HIV, hepatitis and tuberculosis.

In the Declaration of Commitment on HIV/AIDS (2001) and in the Political Declaration on HIV/AIDS (2006), governments have also committed themselves to an approach to HIV that is based on human rights and the full participation of those affected. In particular, they committed themselves “to intensify efforts to ensure a wide range of prevention programmes, including harm-reduction”, “to overcoming legal...or other barriers that block access to effective HIV prevention, treatment, care and support, medicines, commodities and services”, and “to intensify efforts to enact, strengthen or enforce legislation….to eliminate all forms of discrimination against and to ensure the full enjoyment of all human rights of… members of vulnerable groups”. All this in the context of committing “to scale up efforts…with full and active participation of people living with HIV, vulnerable groups.. towards the goal of universal access to…prevention, treatment, care and support by 2010”.

UNAIDS is working hard to support governments to fulfill these commitments, and much progress is being made. In this context, we ask that those engaged in drug control efforts: (1) respect and protect human rights, including the rights of people who use drugs, (2) ensure access to HIV and health and social services to people who use drugs and remove impediments to such access, and (3) allow people who use drugs or their representatives to participate in the design and delivery of HIV and harm-reduction services so that programmes will be as effective as possible.

Progress towards universal access will be reviewed at the High Level Meeting on HIV/AIDS in June where UNAIDS is also supporting the involvement of civil society as critical partners for accountability. In this regard, a representative of people who use drugs is included in the President of the General Assembly's Civil Society Task Force for the High Level Meeting. In order to provide leadership and guidance to governments in the area of HIV and drug use, UNAIDS urges the consideration by the Commission of measures to:

• Help establish a process by which States’ obligations relating to drug control are clarified to ensure that they conform to human rights obligations, and indeed support the achievement of public health and human rights, including universal access to HIV prevention, treatment, care and support.
  
  
• Support States to enact and implement domestic legislation and policy in the area of drug control that will protect human rights and the public health, including of that of people who use drugs, either vulnerable to HIV or already infected.
  
  
• Finally, encourage States to use the High Level Meeting on HIV/AIDS in June and the current review based on the UNGASS on Drugs (1998) to consider and intensify their efforts to address HIV in the context of drug use, including greatly increasing voluntary and effective HIV prevention, treatment, care and support programmes for people who use drugs.

UNAIDS thanks the Commission and its valuable Cosponsor, the UN Office on Drugs and Crime, and offers its full support in any manner possible.

References

Aceijas, Friedman, Cooper, Wiessing, Stimson, Hickman, Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution, Sexually Transmitted Infections, Volume 82, Suppl III, June, 2006.

IPU/UNDP/UNAIDS (2007). Taking action against HIV. A handbook for parliamentarians. Geneva.

Lert F, Kazatchkine M (2007). Antiretroviral HIV treatment and care for injecting drug users: An evidence-based overview. International Journal of Drug Policy 18: 255-261.

Materials produced for UNAIDS Reference Group on HIV and Human Rights, Eighth Meeting, December, 2007.

Office of the United Nations High Commissioner for Human Rights and UNAIDS (2006). International guidelines on HIV/AIDS and human rights (2006 consolidated version). Geneva.

UNAIDS (2005). Intensifying HIV prevention: a UNAIDS policy position paper. Geneva.

UNAIDS (2006). Report on the global HIV/AIDS epidemic. Geneva.

UNAIDS (2007). Practical guidelines for intensifying HIV prevention: Towards universal

access. Geneva.

UNAIDS/WHO AIDS epidemic update, December, 2007

WHO/UNODC Evidence for action series and policy briefs available at http://www.who.int/hiv/pub/idu/en/: Ball et al. (2005)

WHO/UNAIDS/UNICEF (2007). Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report, April 2007. Geneva.

WHO/UNODC/UNAIDS. Technical Guide for Countries to Set Targets for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users (IDUs) (in draft)