[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
HARM REDUCTION OR HARM MAINTENANCE: IS THERE SUCH A THING AS SAFE DRUG
ABUSE?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON CRIMINAL JUSTICE,
DRUG POLICY, AND HUMAN RESOURCES
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
FIRST SESSION
__________
FEBRUARY 16, 2005
__________
Serial No. 109-36
__________
Printed for the use of the Committee on Government Reform
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
CHRISTOPHER SHAYS, Connecticut HENRY A. WAXMAN, California
DAN BURTON, Indiana TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
GIL GUTKNECHT, Minnesota CAROLYN B. MALONEY, New York
MARK E. SOUDER, Indiana ELIJAH E. CUMMINGS, Maryland
STEVEN C. LaTOURETTE, Ohio DENNIS J. KUCINICH, Ohio
TODD RUSSELL PLATTS, Pennsylvania DANNY K. DAVIS, Illinois
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
JOHN J. DUNCAN, Jr., Tennessee DIANE E. WATSON, California
CANDICE S. MILLER, Michigan STEPHEN F. LYNCH, Massachusetts
MICHAEL R. TURNER, Ohio CHRIS VAN HOLLEN, Maryland
DARRELL E. ISSA, California LINDA T. SANCHEZ, California
GINNY BROWN-WAITE, Florida C.A. DUTCH RUPPERSBERGER, Maryland
JON C. PORTER, Nevada BRIAN HIGGINS, New York
KENNY MARCHANT, Texas ELEANOR HOLMES NORTON, District of
LYNN A. WESTMORELAND, Georgia Columbia
PATRICK T. McHENRY, North Carolina ------
CHARLES W. DENT, Pennsylvania BERNARD SANDERS, Vermont
VIRGINIA FOXX, North Carolina (Independent)
------ ------
Melissa Wojciak, Staff Director
David Marin, Deputy Staff Director/Communications Director
Rob Borden, Parliamentarian/Senior Counsel
Teresa Austin, Chief Clerk
Phil Barnett, Minority Chief of Staff/Chief Counsel
Subcommittee on Criminal Justice, Drug Policy, and Human Resources
MARK E. SOUDER, Indiana, Chairman
PATRICK T. McHenry, North Carolina ELIJAH E. CUMMINGS, Maryland
DAN BURTON, Indiana BERNARD SANDERS, Vermont
JOHN L. MICA, Florida DANNY K. DAVIS, Illinois
GIL GUTKNECHT, Minnesota DIANE E. WATSON, California
STEVEN C. LaTOURETTE, Ohio LINDA T. SANCHEZ, California
CHRIS CANNON, Utah C.A. DUTCH RUPPERSBERGER, Maryland
CANDICE S. MILLER, Michigan MAJOR R. OWENS, New York
GINNY BROWN-WAITE, Florida ELEANOR HOLMES NORTON, District of
VIRGINIA FOXX, North Carolina Columbia
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
J. Marc Wheat, Staff Director
Nick Coleman, Professional Staff Member
Malia Holst, Clerk
Sarah Despres, Minority Counsel
C O N T E N T S
----------
Page
Hearing held on February 16, 2005................................ 1
Statement of:
Bahari, Zainuddin, CEO, Humane Treatment Home, Malaysia...... 59
Bensinger, Peter, president and CEO, Bensinger, Dupont &
Associates................................................. 56
Beyrer, Chris, M.D., M.P.H, Johns Hopkins Bloomberg School of
Public Health.............................................. 68
How, Tay Bian, director, Drug Advisory Programme, the Colombo
Plan Secretariat, Sri Lanka................................ 63
Newman, Robert G., M.D....................................... 90
Pathi, Mohd Yunus............................................ 80
Peterson, Robert, Pride International Youth Organization;
Rev. Edwin Sanders, Metropolitan Interdenominational
Church, member, President's Advisory Commission on HIV/
AIDS; Peter L. Beilenson, M.D., commissioner, Baltimore
City Department of Health; Eric A. Voth, M.D., FACP,
chairman, the Institute on Global Drug Policy; and Andrea
Barthwell, M.D., former Deputy Director, Office of National
Drug Control Policy........................................ 115
Barthwell, Andrea, M.D................................... 145
Beilenson, Peter, M.D., M.P.H............................ 131
Peterson, Robert......................................... 115
Sanders, Rev. Edwin...................................... 129
Voth, Eric A., M.D., FACP................................ 137
Syarif, Syahrizal............................................ 99
Letters, statements, etc., submitted for the record by:
Bahari, Zainuddin, CEO, Humane Treatment Home, Malaysia,
prepared statement of...................................... 61
Barthwell, Andrea, M.D., former Deputy Director, Office of
National Drug Control Policy, prepared statement of........ 148
Beilenson, Peter L., M.D., commissioner, Baltimore City
Department of Health, prepared statement of................ 134
Bensinger, Peter, president and CEO, Bensinger, Dupont &
Associates, prepared statement of.......................... 58
Beyrer, Chris, M.D., M.P.H, Johns Hopkins Bloomberg School of
Public Health, prepared statement of....................... 71
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, NIH response........................ 8
Davis, Hon. Danny K., a Representative in Congress from the
State of Illionois, letter dated February 11, 2005......... 109
How, Tay Bian, director, Drug Advisory Programme, the Colombo
Plan Secretariat, Sri Lanka, prepared statement of......... 65
Newman, Robert G., M.D., prepared statement of............... 92
Pathi, Mohd Yunus, prepared statement of..................... 84
Peterson, Robert, Pride International Youth Organization,
prepared statement of...................................... 120
Souder, Hon. Mark E., a Representative in Congress from the
State of Indiana:
Letter dated February 11, 2005........................... 43
Prepared statement of.................................... 4
Voth, Eric A., M.D., FACP, chairman, the Institute on Global
Drug Policy, prepared statement of......................... 139
HARM REDUCTION OR HARM MAINTENANCE: IS THERE SUCH A THING AS SAFE DRUG
ABUSE?
----------
WEDNESDAY, FEBRUARY 16, 2005
House of Representatives,
Subcommittee on Criminal Justice, Drug Policy, and
Human Resources,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:45 p.m., in
room 2154, Rayburn House Office Building, Hon. Mark E. Souder
(chairman of the subcommittee) presiding.
Present: Representatives Souder, McHenry, Brown-Waite,
Cummings, Norton, Davis of Illinois, Watson, Waxman,
Ruppersberger and Higgins.
Staff present: Marc Wheat, staff director; Nick Coleman and
Brandon Lerch, professional staff members; Pat DeQuattro and
Dave Thomasson, congressional fellows; Malia Holst, clerk;
Sarah Despres and Tony Haywood, minority counsels; Josh
Sharfstein, minority professional staff member; Earley Green,
minority chief clerk; and Jean Gosa, minority assistant clerk.
Mr. Souder. The subcommittee will now come to order.
Good afternoon, and thank you all for coming. Today we are
holding our subcommittee's second official hearing of the 109th
Congress. Last week, we held a hearing with the Director of the
White House Office of National Drug Control Policy to get a
clear understanding of how the Federal drug budget brings
resources to bear on reducing drug abuse, whether it be law
enforcement, drug treatment or drug use prevention. Today we
will focus on how the public's resources and trust may be
abused through programs that fit under the self-identified
label of harm reduction.
I believe this subcommittee was the first to hold a hearing
on measuring the effectiveness of drug treatment programs and
was the first to hold a hearing on the President's Access to
Recovery initiative, which seeks to increase and enhance the
availability of drug treatment in the United States. In the
last Congress, many members of this subcommittee worked
together to pass the Drug Addiction and Treatment Expansion Act
and will do so again this Congress. The members of this
subcommittee are not just talkers, we are doers, and I'm
pleased that we have the opportunity to work on so many
important matters together.
As President Bush refers to it in the National Drug Control
Strategy, we should all work for healing America's drug users.
I applaud the administration's 50 percent increase to the
Access to Recovery program for a total of $150 million. This
initiative, administered by the Substance Abuse and Mental
Health Services Administration [SAMHSA], will provide people
seeking clinical treatment and/or recovery support services
with vouchers to pay for the care they need. And it will also
allow assessment of need and will provide vouchers for clients
who require clinical treatment and/or recovery support services
but would not otherwise be able to access care.
As I stated last week, when evaluating drug control
policies, we must look beyond the intent of the program and
look at the results. We should always apply a common-sense
test: Do the policies in question reduce illegal drug use? That
is the ultimate performance measure for any drug control
policy, whether it is related to enforcement, treatment or
prevention. If we apply that test to Federal drug programs on
the whole, the Bush administration is doing very well. Drug
use, particularly among young people, is down since President
Bush took office in 2001. Under this administration, we have
seen an 11 percent reduction in drug use, and over the last 3
years, there has been a historic 17 percent decrease in teenage
drug use. That is in stark contrast to what happened in the mid
to late-90's when drug use, particularly among teenagers, rose
dramatically after major declines all through the 1980's and
early 1990's.
Now, what if we were to apply that same test to that of
``harm reduction?'' It wouldn't even be close. Harm reduction
does not have the goal of getting people off drugs. Harm
reduction is an ideological position that assumes certain
individuals are incapable of making healthy decisions.
Advocates of this position hold that dangerous behavior, such
as drug abuse, must be accepted by society, and those who
choose such lifestyles, or become trapped in them, should be
able to continue these behaviors in a manner less harmful to
others. Often, however, these lifestyles are the result of
addiction, mental illness and other conditions that should and
can be treated rather than accepted as normal healthy
behaviors.
Instead of addressing the symptoms of addiction--such as
giving them clean needles, telling them out how to shoot up
without blowing a vein, recommending that addicts abuse with
someone else in case one of them stops breathing--we should
break the bonds of their addiction and make them free from
needles and pushers and pimps once and for all.
We have a wide variety of witnesses today. Our first panel
includes several gentlemen who worked with faith-based
organizations in Asia, primarily with Muslim organizations in
Afghanistan, Malaysia, and Indonesia and are having to contend
with needle giveaway programs that are being promoted by
foreigners, notwithstanding the cultural traditions of these
countries in question. Some of these ``harm reduction''
programs, I must add with embarrassment and with apology to the
gentlemen of the first panel, are financed by the U.S. Agency
for International Development, the Federal Government foreign
aid agency.
On the other hand, one of the witnesses requested by the
minority, Dr. Beilenson, worked several years ago on a project
which critics might call ``More Drugs for Baltimore.''
In June 1998, the Baltimore Sun reported that Johns Hopkins
University drug abuse experts and Baltimore's health
commissioner were, ``discussing the possibility of a research
study in which heroin would be distributed to hard core addicts
in an effort to reduce crime, AIDS and other fallout from drug
addiction.'' At that time, ``Public health specialists from a
half dozen cities in the United States and Canada met at the
Lindesmith Center, a drug policy institute supported by
financier George Soros, to discuss the logistics and politics
of a multicity heroin maintenance study.'' Such an endeavor
would be, `` `politically difficult but I think it's going to
happen,' said Baltimore Health Commissioner Dr. Peter
Beilenson.''
Another minority witness, Dr. Robert Newman, served on the
board of directors for the Drug Policy Foundation as early as
1997, and presently serves on the board of directors with
another minority witness, Reverend Edwin Sanders, of the Drug
Policy Alliance, the new name of the Drug Policy Foundation
since its merger with the aforementioned Lindesmith Center. The
Drug Policy Alliance described itself as, ``the Nation's
leading organization working to end the war on drugs.'' Along
with its major drug donor, George Soros, it helped produce,
``It's Just a Plant,'' a pro-marijuana children's book, which I
have a copy of here.
I would be very interested in learning from the witnesses
today what they believe the U.S. Government policy should be
with respect to financing heroin distribution, safe injection
facilities and how-to manuals like ``H Is for Heroin,''
published by the Harm Reduction Coalition, and other children's
books on smoking marijuana produced with the help of the
organization run by two of the minority's witnesses today.
We thank everyone for traveling so far and taking the time
to join us. We look forward to your testimony.
And I now yield to Mr. Cummings, the ranking member of the
subcommittee.
[The prepared statement of Hon. Mark E. Souder follows:]
Mr. Cummings. Thank you very much, Mr. Chairman. And I
thank you for holding this hearing today on harm reduction
strategies for preventing illness and death among injecting
drug users, their loved ones and the broader population. I am
pleased that we are joined today by the ranking minority member
of the full committee, Mr. Henry Waxman. Mr. Waxman's
outstanding leadership on matters of public health is truly
commendable and I welcome his participation.
I also welcome all of our witnesses. A number of them have
traveled a considerable distance to share their perspectives on
harm reduction and needle exchange, and I appreciate their
being with us today.
As you know, Mr. Chairman, injecting drug users are at
elevated risk for infection with HIV and other blood-borne
diseases due to widespread use of contaminated injection
equipment. In the United States, Russia and most of Asia,
including China, injection drug use is a major risk factor
driving HIV infection rates in these highly populous and, in
many cases, highly vulnerable societies. The enormous unmet
need for drug prevention and treatment in these countries,
therefore, is not just a concern from the standpoint of drug
policy. It is a major factor in a global AIDS epidemic, and it
desperately requires effective interventions to halt the spread
of HIV/AIDS among injecting drug users and the broader
population.
Needle and syringe exchange has proved to be an effective
intervention to prevent HIV infection among injection drug
users. The science supporting the efficacy of needle exchange
is thorough and consistent to the point that, today, there
really is no serious scientific debate about whether needle
exchange programs work as part of a comprehensive strategy to
reduce HIV infection among high-risk injection users. Indeed,
numerous scientific reviews conducted in the United States and
internationally confirm that syringe exchange programs, when
implemented as part of a comprehensive HIV/AIDS prevention
strategy, are effective in reducing the spread of HIV and other
blood-borne illnesses.
The most comprehensive of these was the review conducted by
the U.S. Department of Health and Human Services in the year
2000. Summarizing this report, then-Surgeon General David
Thatcher concluded, after reviewing all of the research to
date, ``The senior scientists of the department and I have
unanimously agreed that there is conclusive evidence that
syringe exchange programs as part of a comprehensive HIV
strategy, are an effective public health intervention that
reduces the transmission of HIV and does not encourage the use
of illegal drugs.''
Similarly, a 2004 review of the scientific literature by
the World Health Organization found that with regard to
injecting drug users, ``There is compelling evidence that
increasing the availability and utilization of sterile
injecting equipment reduces HIV infection substantially.''
Last fall, at the request of Mr. Waxman and myself, the
National Institutes of Health conducted a further review on the
scientific literature to date and reported to us that the
Federal Government has extensively examined the effectiveness
of syringe exchange programs [SEPs], dating back to 1993,
including reviews by the Government Accountability Office. The
current scientific literature supports the conclusion that SEPs
can be an effective component of a comprehensive, community-
based HIV prevention effort.
With unanimous consent, I would like to submit the NIH
response for the record.
[The information referred to follows:]
Mr. Cummings. Not surprisingly, these comprehensive reviews
validate research that has focused on needle exchange in my own
city of Baltimore. For more than a decade, Dr. Beilenson has
overseen these efforts as Commissioner of the Baltimore City
Health Department. I am pleased that he joins us today on the
second witness panel and will discuss his research and his
experience in detail.
But suffice it to say, Mr. Chairman, the bottom line in
Baltimore, as it has been elsewhere, is that needle exchange is
a fundamental component of any comprehensive approach to
reducing HIV infection. Studies show that needle exchange
programs like Baltimore City's reduce the number of
contaminated needles in circulation, reduce the likelihood of
HIV infection, bring the highest-risk injecting drug users into
contact with treatment resources and other critical social
resources and do not increase drug use, the number of injecting
drug users, or the volume of contaminated needles discarded in
the streets.
These programs save lives, and that is why they have the
unequivocal support of organizations like the American Medical
Association, the U.S. Conference of Mayors, the National
Academy of Sciences, the American Academy of Pediatrics, the
International Red Cross and UNICEF, to name just a few.
Religious groups and denominations including the Episcopal
Church, the Presbyterian Church, United Church of Christ and
the Progressive Jewish Alliance, to just name a few, also
support making sterile needles available. In States from
coasts, Maryland and California included, recognize that needle
exchange is not just effective, it is cost effective and even
saves taxpayers money, given the fact of the avoided costs of
treatment with HIV/AIDS patients.
Those who state categorical arguments against harm
reduction seem to overlook the fact that harm reduction is at
the root of many mainstream measures to protect public health
in areas of activity such as transportation or engagement in an
activity involved in the inherent risk of injury or death.
Speed limits, seatbelt laws and child safety seats, to cite a
few familiar examples, all presuppose that the dangers inherent
in vehicular transportation cannot be eliminated, but that the
number and severity of injuries can be reduced substantially
for drivers, passengers and innocent bystanders alike.
No one in this room disputes the fact that drug abuse is
inherently unhealthy behavior. Needle exchange is a proven
means of empowering injecting users to take action to protect
themselves, their sexual partners and their children from the
potentially fatal secondary risk of an infection with HIV and
other deadly or debilitating blood-borne diseases. An injecting
drug user who takes advantage of a needle exchange program is
more likely to need treatment and more likely to obtain
treatment than his or her counterpart who is outside the
treatment system and not exchanging contaminated needles for
sterile ones. Such a user is more likely to reduce the number
of injections or to stop injecting altogether and is less
likely to become infected or infect someone else with HIV.
The proven benefits of participating in a treatment program
include reduced drug consumption, reduced risky health
behavior, improved overall health, increased stability in
housing and employment, reduced criminal activity and
identification and treatment of mental health problems.
Only a misinterpretation of the scientific literature could
lead one to conclude that needle exchange programs are
ineffectively reducing HIV or that they recruit new drug users
or increase drug use. Strangely enough, however, we have seen
this happen with a number of studies that support the efficacy
of needle exchange.
The Vancouver Injecting Drug User Study is routinely cited
by harm reduction opponents to support the erroneous view that
needle exchange is ineffective and actually contributes to
increases in drug use and HIV infection. In fact, as that
study's authors have been compelled to point out, the Vancouver
data confirms the program's effectiveness in reaching addicts
most in need of treatment and most at risk for HIV infection.
With unanimous consent, Mr. Chairman, I would like to
submit the letters from researchers at the National Institutes
of Health refuting congressional misinterpretations of their
research on needle exchange.
Mr. Chairman, today's hearing is likely to be one of
numerous congressional hearings designed to scrutinize public
health programs that fall under the broad umbrella of harm
reduction. I hope we can help to demystify that term today and
examine these programs from an objective public health point of
view, rather than through the often distorted lens of ideology.
I also hope that as the public debate on harm reduction
advances, we will be united in our motivation to preserve and
protect the health and life of injecting drug users, their
sexual partners, their children and the broader community. If
we do that, I believe we can build a political consensus of
support for needle exchange that mirrors the scientific one,
and many more lives may be saved as a result.
With that said, I would like to conclude by closing my
opening statement, but not without first alluding to you for
your leadership in introducing harm reduction legislation of
your own that would make ripamorphine more readily available
for the treatment of heroin addiction.
I am proud to say that I was an original cosponsor of the
Drug Addiction Treatment Expansion Act in the last Congress,
and I look forward to continuing to work with you on that
legislation and other important drug policy and public health
matters.
I look forward to the testimony of all our witnesses today,
and I thank them for being with us. And with that, I yield
back.
Mr. Souder. I would like to yield to Ms. Norton of the
subcommittee for an opening statement.
Ms. Norton. Thank you, Mr. Chairman.
Mr. Chairman, I find this hearing a little curious,
particularly during your first hearing on reentry where there
is a major problem in the United States that you focused us on,
the entry of many offenders back into the population. This is a
Federal hearing on harm reduction strategies that I have not
seen advocated in the Congress of the United States. I know of
no bill here for needle exchange programs. I do know that many
in the States and cities have taken leadership on programs such
as needle exchange, even medical marijuana, under the theory of
Federal control and respect for self-government and people's
ability to know best what works in their own local communities.
If anything, the people of the District of Columbia deeply
resent that we are the only jurisdiction in the United States
that has not been able to use its own money to pay for a needle
exchange, despite its proven effectiveness, according to the
most respected scientific organizations in our country.
I notice a series of witnesses from foreign countries. I
have a 3 p.m. appointment. I am going to rush back so that I
can see what the relevance is of their experience to our own
experience. I caution us all that the American experience in
this very affluent country with drug addiction but--may be sui
generis, but I would be glad to hear whether or not this
experience is, in fact--can teach us something.
Mr. Chairman, I would like to take some exception with your
memo and say, if you are going to include under harm reduction
things like needle exchange, and then say, those who hold it
are of the view that drug abuse therefore simply must be
accepted by society and those who choose such lifestyles--and I
am quoting from your memo and statement.
I just wish to take serious objection to the notion that to
people, like the people on this panel, for example, who favor
certain kinds of approaches--``harm reduction'' is not a term
with which I'm very familiar--accept the position that those
who might use these approaches, choose these lifestyles, want
these lifestyles; and we must accept the fact that we believe
that we can do nothing with them.
And you go on to talk about, that they are incapable of
changing and so forth. And that language is very, very
objectionable and very, very misconstrued in this country--if
you are going to write such stuff in black and white, that you
say who it is that believes those things. Because by putting us
all under the same rubric, it seems to me you do offense to the
position of many of us.
For example, I am deeply opposed to heroin maintenance,
marijuana maintenance. I'm not going to go back to the people
in my district, left without any economy except the drug
economy and say, I'll tell you what, I've got a good thing for
you; we are going to maintain you on heroin, and this problem
will be all over.
I don't know anybody in my community who is for needle
exchange who would be for heroin maintenance or legalization of
drugs. And I don't enjoy of being put in a barrel with the
people, whoever they are, you are talking about.
We are not for harm reduction. We, in the District of
Columbia, we in places like Baltimore and the great cities of
the United States, like death reduction.
Needle exchange, to take the most prominent example, is a
fairly new approach in our communities. When I was a kid
growing up in the District of Columbia, there were people on
heroin. They were small in number and in small sections of the
city; and then it spread to other sections.
You say we should do all we can to break the bonds of
addiction. What do you think we have been doing for decades
now? And who is incapable of leaving addiction? Not the people
who are addicted, but the government that has been incapable of
finding the strategies that could help people like the people I
represent. And we ought to admit we have been incapable of it.
And when we find a strategy that reduces death in our
community, and the best scientific minds in the United States--
not in some developing country, in the United States--tell us
this works, you betcha that's exactly what we ought to do. And
when everybody from the CDC and NIH to the AMA and the
Pharmaceutical Association of America tell me that, according
to their studies, approaches like needle exchange reduce death
in our country, that is who I am going to listen to.
If you have people from foreign countries that are on the
level of these people in their scientific background and
information, I will be very pleased to hear from them. But I
thought we had the best science in the United States.
Finally, let me say, Mr. Chairman, we are--whatever people
may think of addicts themselves, we are seriously concerned
that women and children who have nothing to do with addiction
are increasingly the victims of addiction because not only do
we not put up the funds, do we not have the strategy to stop
addiction in this rich country full of the best science in the
world, but we have not even employed strategies to keep
diseases like HIV/AIDS, Hepatitis B, Hepatitis C from being
spread to parts of the community who had nothing to do with
those--with that addiction.
Therefore, I think we've got to work together to save
lives, and not put us all under some big rubric as if we all
had our positions on these issues funneled in from across the
seas or as if we could not in this country get ourselves
together and figure how to prevent addiction and, two, how to
keep addiction from spreading among the most vulnerable
populations.
And if I may say so, Mr. Chairman, those populations tend
to be disproportionately people of color, who very much resent
being told that they belong with some strategy where people
believe they are incapable of getting out of the lifestyle that
they now find themselves in. They are not incapable; it is the
government that has been incapable.
Mr. Souder. I would like to just--for committee order, we
have had two straight statements that were more than double the
length, and we need to make sure our statements are within
reason. I am very generous, unlike most committees, in allowing
everybody to do statements, but we have to stick tighter to the
timeframe.
Mr. Waxman, thank you for coming. Did you want to make a
statement? Mr. Waxman.
Mr. Waxman. Thank you very much, Mr. Chairman. The starting
point for today's hearing is a critical public health problem,
the harm substance abuse causes to our citizens, society and
the world. In every American city and town, all across the
world, illegal drug use destroys lives, tears families apart
and undermines communities. Among the most lethal addictions is
addiction to opiates. Heroin users can die from overdoses, die
from overwhelming infections at injectionsites and die from
heart damage. Many also die from infectious diseases.
A hearing to focus attention on the best public health
strategy to fight this enormous toll of suffering would serve a
very useful purpose, but this does not appear to be that kind
of hearing. Instead, this hearing appears designed to discredit
needle exchange programs which exist in many U.S. cities and
around the world.
This is not a tactic that will strengthen our Nation's
substance abuse policy or improve our Nation's health. Needle
exchange programs are well supported by scientific evidence and
serve a number of important roles.
Mr. Chairman, you stated in your memo and in your opening
statement that those who have that point of view are being
ideological. I don't know who is being ideological. Let's be
pragmatic and figure out what works, and the best way to figure
out what works is to look at the evidence and look at the
science and listen to the experts.
If you could show me these programs didn't work, then I
would say that no one should want to continue them. But if we
hear from experts that they do work, you should want to do
whatever works. According to the scientific evidence, these
programs don't just provide access to clean needles, they also
educate drug users about the danger of sharing needles. And
according to the National Institutes of Health, needle exchange
is associated with reductions in the incidence of HIV,
Hepatitis B and Hepatitis C in the drug-using population.
Certainly that's an important objective.
One major study cited by NIH found that in 52 cities
without needle exchange programs, HIV rates were increased. But
where they had needle exchange, HIV rates dropped. I think
that's an important pragmatic conclusion in countries like
Russia where three-quarters of HIV transmission occurs through
intravenous drug use.
Needle exchange programs can be one of the most effective
interventions to stop the spread of this deadly disease. So if
we see that using needle exchange stops the spread of disease
like HIV/AIDS and Hepatitis, that's a good goal.
The second benefit of needle exchange programs is the
access they provide to drug users themselves. Needle exchange
programs can be the stepping stone to substance abuse treatment
and ending drug use altogether. Mr. Chairman, your point of
view seems to say that's what we want and using needle
exchanges is preventing that from happening.
Well, what we are hearing from some of the people who are
most familiar with the drug abuse program, exactly the opposite
is the case. If they come in for a needle exchange program,
that gives an opportunity for the health programs--health
community to reach out to them to stop using drugs completely.
I am strongly opposed to drug use, but there is no evidence
that needle exchange programs encourage drug use. To the
contrary, the National Institutes of Health has stated, ``A
number of studies conducted in the United States have shown
that syringe exchange programs do not increase drug use among
participants or surrounding community members.'' I would be
concerned if it increased drug use. But the experts who are
looking at the operation of the programs in the real world tell
us the opposite is true.
So this committee has a fundamental choice to make. Are we
for using science to improve public health or are we for
ignoring the science, ignoring the evidence and then stating we
are going to follow a course of action no matter what the costs
may be? If that's the choice we make, that, to me, is putting
ideology over science.
The issues at stake could not be more serious. HIV/AIDS
kills 3 million people every year. Other infectious diseases,
such as Hepatitis B and C, cause pain and suffering to millions
more. We can approach these enormous health problems by asking
our best public health experts what works and following an
evidence-based approach. I think this is an important choice.
We all come down on the side of health and we should see what
could advance that goal.
I think it's worth listening to the witnesses on all sides
and whatever they have to say. I'm not going to prejudge a
witness before they even have something to say at a hearing and
say that their views show them not to be credible. Let's hear
what they have to say and cross-examine them.
One final point I want to make. I saw a copy of a letter
sent by Chairmen Davis and Souder to Secretary of State
Condoleezza Rice and USAID Director Andrew Natsios. These
letters are a direct attack on needle exchange programs and
they literally ask for every document in the State Department
related to these programs. As their primary evidence for the
dangers of needle exchange, they cite the March 2004, report of
the International Narcotics Control Board, the drug agency of
the U.N. They characterize this report as having sharply
criticized needle exchange programs because such policies
encourage drug use.
I read the U.N. report that Chairmen Souder and Davis cite,
and I ask unanimous consent to insert them in the record. These
letters mischaracterized them. In fact, regarding needle
exchange, the report states that in a number of countries,
governments have introduced since the end of the 1980's
programs for the exchange or distribution of needles and
syringes for drug addicts with the aim of limiting the spread
of HIV/AIDS. The board maintains the position, the position
expressed by it already in 1987, that governments need to adopt
measures that may decrease the sharing of hypodermic needles
among injecting drug abusers in order to limit the spread of
HIV/AIDS. Rather than simply sharply criticizing the needle
exchange programs, this explains that such an effort can save
lives.
So I would point out that the report does not state, as the
letter alleges, that needle exchanges encouraged drug use, nor
does the report state, as the letter also alleges, that needle
exchange programs violate international agreements. The United
Nations, CDC and NIH, and all public health experts, recognize
the vital role of needle exchange programs; and I think we
should give a lot of attention to what they have to say.
I thank all the witnesses for coming today, and I look
forward to their testimony.
Mr. Souder. Before proceeding, I would like to take care of
a couple of procedural matters.
First, I ask unanimous consent that all Members have 5
legislative days to submit written statements and questions for
the hearing record, and that any answers to written questions
provided by the witnesses also be included in the record.
Without objection, so ordered.
Mr. Waxman. I had made a unanimous consent request to put
in----
Mr. Souder. That's my second one. I ask unanimous consent
that all exhibits, documents and other materials referred to by
Members and witnesses may be included in the hearing record,
including those already asked by Mr. Waxman and Mr. Cummings;
and that the witnesses may be--and all these be included in the
hearing record--in addition to the Members, anything the
witnesses may refer to; and all Members be permitted to revise
and extend their remarks.
Without objection, it is so ordered.
[The information referred to follows:]
Mr. Souder. I also would like to insert into the record the
International Narcotics Control Board section on measures to
reduce harm that Mr. Waxman just referred to, the section on
HIV. There it said they regretted that the discussion on harm
reduction has diverted attention from primary prevention and
abstinence treatment. They also, in there, said it should not
be carried out at the expense of other important activities--
reduce the demand.
It also criticizes those who opt in favor of drug
substitution and maintenance. It says facilities have been
established where injecting drug abusers can inject drugs that
they have acquired illicitly. The Board has stated on a number
of occasions, including its recent annual report, that the
operation of such facilities remains a source of grave concern;
reiterates that they violate the provisions of international
drug control conventions. It also says, in conclusion of this
section, that harm reduction measures and their demand
reduction strategies carefully analyze the overall impact of
such measures which may sometimes be positive for an individual
or for a local community while having far-reaching negative
consequences at national and international levels.
So there are multiple methods of interpretation of
different sections, but as it relates to harm reduction, that
report was pretty clear. And I know--because of our tremendous
respect for each other, we have been going back and forth with
letters, and I know we have a deep difference of opinion, but
we need to be careful about how we mischaracterize each other's
letters. And I believe that was a mischaracterization of our
interpretation of the letter. We disagree on a number of the
scientific facts and backgrounds on these reports, but I don't
think anybody is deliberately trying to distort a report, as
was implied in there.
Mr. Waxman. I just want to point out that I don't think
that report stands for the characterization that you and
Chairman Davis made from that report. And we will let the
documents speak for themselves.
I am not suggesting that you did anything intentionally
wrong, but I think you were certainly mistaken in your
interpretation of it. I think many U.N. reports and statements
support needle exchange as part of a comprehensive approach to
drug abuse, and I think putting it in that context is that
clarification.
Mr. Souder. If the witnesses on the first panel would come
forward. We moved Dr. Peter Bensinger to the first panel
because we got such a late start, and with our long opening
statements. If you could come forward and remain standing, it
is the tradition of this committee, as an oversight committee,
it is our standard practice that all witnesses testify under
oath.
If you each raise your right hand.
[Witnesses sworn.]
Mr. Souder. Let the record show that each of the witnesses
responded in the affirmative.
And you can go ahead and take a seat. We appreciate that. I
will introduce you each as your turn comes up, and we will go
left to right. And Dr. Peter Bensinger is president and CEO of
Bensinger, Dupont & Associates. Thank you for coming today.
STATEMENT OF PETER BENSINGER, PRESIDENT AND CEO, BENSINGER,
DUPONT & ASSOCIATES
Mr. Bensinger. Thank you very much, Mr. Chairman, members
of this committee, some of whom I had the opportunity of
appearing before almost 25 years ago when I served as the
Administrator of the U.S. Drug Enforcement Administration under
Presidents Ford, Carter and Reagan. And I commend the Chair and
the Members for shedding light and hearing evidence and
testimony and, in my case, both personal impressions and
anecdotal situations dealing with harm reduction.
The theory that accepting illegal drug use, by accepting
that the injection of heroin is preferable to discouraging such
use by sanctions, by education, by prevention, by treatment, by
law enforcement, I think is a mistake. I felt it was a mistake
when I served in the role as Administrator.
I went to Zurich, Switzerland. I saw the needle exchange
park. It was a disaster. It increased crimes around the site,
increased addiction, increased the problems of health.
The Vancouver study was referenced, and I'm not an
epidemiologist or research scientist, but the data of 2003
indicates that HIV prevalence was 35 percent, that the
incidence of injection use for Hepatitis C was 82 percent among
users, and that the rates went up since the needle exchange
program got started.
I'm sympathetic, and Congressman Waxman and I have
exchanged views over the decades, and I respect his long-time
experience in the health care field and the legislation which
he has promulgated. But I don't agree with him, and I say so
respectfully, and truly with respect, that the needle exchange
is not going to prevent diseases.
See, I think heroin addiction--I believe this is a disease,
the addiction itself. And what's happening is, the needle
exchange programs are enabling people to continue on with
unhealthy, illegal and, in some cases, deadly behavior.
I don't think the message of harm reduction and needle
exchange is as effective as having consequences for that use,
having treatment for that use, having deterrence for that use,
having education for that use. Any behavior that is destructive
to health and safety must be discouraged with consequences, Mr.
Chairman, not enabled without them.
I also have worked with the International Control Board for
many years. Clearly, the INCB and the psychotropic conventions
on drugs establishes that the possession and purchase of drugs
for non-medical use represents a criminal offense. That hasn't
changed. We haven't amended that treaty, and I would doubt if
the International Control Board would like to sanction needle
exchange rooms any more than they sanctioned opium dens back
when these laws went on the books.
In terms of my own personal experience--and I will complete
my testimony because there are other witnesses to give their
own point of view. But in the 1970's when I took on the
assignment at DEA, we had 2,000 heroin overdose deaths a year.
The white paper on drug abuse in 1975, which President Ford,
Nelson Rockefeller and Congress adopted, put this as our No. 1
priority. Heroin overdose deaths went down to 800 a year from
2,000 in 4 years--without needle exchanges, but with the high
priority of law enforcement and treatment and cooperation with
Mexico.
In the 1980's, Nancy Reagan, with the help of Congress and
the American public and parent group movements, embraced the
``Just Say No'' policy. And the cocaine use, which in the mid-
80's was 4.8 to 4.9 million regular users, every-30-day users,
of cocaine and crack went down to less than 2 million today.
And that wasn't through making a conversion pipe from crack to
a safer form of cocaine; that was by establishing clear
sanctions and enforcing the law and providing a lot of good
education and the benefit of the parent group movements that
did want their kids to stop.
I used to be director of corrections and started the first
drug abuse treatment program in the State penitentiary system
in Illinois back in 1970. And I'm sympathetic to wanting to get
people who have drug abuse into treatment and off heroin,
methadone, whatever type of addiction and drug they're used to.
But in Sweden, they took a clear approach; they said, ``We
are going to enforce the laws.'' In Australia, they took an
approach that said, ``We are going to decriminalize marijuana
and adopt harm reduction.'' And my written testimony, offered
for the record, describes the comparative findings of lifetime
drug use.
In Sweden, 16 to 29-year-olds were 29 percent; Australia 52
percent. Use in the previous year: 1 out of 50 in Sweden; 1 out
of 3 in Australia. Heroin users, under age 20: Sweden, 1\1/2\
percent, Australia, five times that amount. Drug deaths per
million: Sweden, 23; Australia, 48. Drug offenses per million:
Sweden was three times the number of Australia because they did
arrest people.
But the result in terms of the health consequences would
reflect that Sweden was more successful in curbing the adverse
effects of drug abuse by confronting it head on.
I would conclude my testimony with a sense of perspective,
I guess gained over 35 to almost 40 years in public service
from the Youth Commission to Corrections to Interpol and to the
DEA under three different administrations. I don't think there
is anything wrong with treatment, education and prevention. I
don't think we have done enough of it. But I don't think the
answer is to say, ``Continue use and abuse, continue to be
addicted; here are some needles to break the law.''
Thank you, Mr. Chairman and members of the committee.
[The prepared statement of Mr. Bensinger follows:]
Mr. Waxman. Mr. Chairman----
Mr. McHenry [presiding]. We are actually holding off with
questions.
Mr. Waxman. I have to leave and I wanted to say, Mr.
Bensinger--with all due respect, he characterized what he
thought were my views.
I wasn't giving my views. I was giving the views of the NIH
and CDC and other agencies, and I put those views out. I stand
to listen and see what works, and I wanted to put that out and
to express my regrets that I have a conflict in my schedule.
Mr. McHenry. The Chair thanks the ranking member of the
full committee. And as a freshman Member, I make sure I thank
my senior Members because I would like to be here again.
Thank you, sir, for your testimony.
Mr. Bahari.
STATEMENT OF ZAINUDDIN BAHARI, CEO, HUMANE TREATMENT HOME,
MALAYSIA
Mr. Bahari. Thank you, Mr. Chairman. Unlike my esteemed
fellow panelists, this is the first time that I'm giving
testimony to this committee. I thank you for this opportunity
to inform the committee on my program and my views on harm
reduction.
I'm from Malaysia. I once was in the Civil Service, and I
headed my country's agency that is responsible for managing and
reducing the drug abuse problem. In that capacity, I was also
involved in planning and implementing various action programs
dealing with prevention, treatment and rehabilitation. I'm now
retired and am running my own facility for the treatment of
drug dependence.
I'm also involved in some of the training programs being
organized by the Drug Advisory Programme of the Colombo Plan
for the South and East Asia region. In this capacity, I'm
presently involved in organizing and implementing faith-based
programs for both prevention as well as treatment of drug
dependence.
I'm a Muslim, and Islam is a major religion in South and
East Asia. From an Islamic perspective, drugs are a form of
intoxicants and all intoxicants are forbidden to all Muslims.
This observation is also a mandatory requirement to all the
other major religions in South and East Asia. In cognizance of
this, harm reduction programs, which implies the continued
consumption of drugs, is unacceptable. Treatment programs must
be directed toward the goal of complete abstinence.
Needle exchange, safe injectionsites and heroin maintenance
programs are delusions which cannot bring about the results
that they are supposed to. A drug addict is an undisciplined
person who observes no rule or regulations. His own life is
regulated by the need to satisfy his craving, and in attempting
to achieve this, he breaks all norms of civilized behavior.
Can we realistically expect him to bring his old needle to
exchange for a new one? He will be going to the needle exchange
site only to get new needles. And who is to regulate and
supervise to ensure that the needle is not shared in his
intoxicated state? Can we seriously believe that he would be
worried about contaminated needles?
I have heard statements to the effect that needle exchange
is effective as part of a comprehensive approach to drug abuse.
Now, this implies that in an environment where the approach is
not comprehensive, needle exchange will be a failure. There are
very few countries that I have come across that have such a
comprehensive approach to drug abuse. They will take it in
parcels and needle exchange as part of a program without having
a comprehensive approach in terms of controlling and
maintaining drug abuse.
The same applies to the methadone maintenance program. Free
heroin is not ultimately translated into non-heroin use.
Addicts who have been in a methadone maintenance program
admitted to continued heroin use. Methadone maintenance
programs can only be successful in a fully controlled
environment. This implies indefinite incarceration of the
addict and renders the whole exercise futile.
Admittedly, there are NGO's in South and East Asia that
appear to be supportive of harm reduction programs. This is
only because they receive financial support from certain
interests in return for which we have to support the program.
Sweeping statements have been made by advocates of harm
reduction on the failure of drug treatment programs. On closer
examination, one finds that most of such statements came from
non-practitioners. While it is true that some treatment
programs have been failures, it is only because those programs
are structurally weak.
Many facilities with sound and pragmatic programs show
significant successes in the treatment programs. Structurally
weak programs can be strengthened through further training.
There is no reason to abandon existing treatment programs.
Let me conclude my testimony by reiterating that treatment
works albeit not without some difficulties. Harm reduction,
whether it be needle exchange, methadone maintenance or
injectionsites, encourages an addict to continue with a
lifestyle that ultimately brings no benefit to either himself
or to society.
Thank you.
[The prepared statement of Mr. Bahari follows:]
Mr. Souder [presiding]. Thank you. And thank you again for
coming so far to give testimony. And anything you heard in my
opening guidelines to the committee, if you want to give us any
additional documents and materials for the record on what your
program does and how successful it has been, I would appreciate
that.
I am sure we're going to mispronounce names. So as I say
your name, when you start, you can say it correctly so I can
get it right the second time.
Tay Bian How is director of the Drug Advisory Programme of
the Colombo Plan Secretariat in Sri Lanka.
STATEMENT OF TAY BIAN HOW, DIRECTOR, DRUG ADVISORY PROGRAMME,
THE COLOMBO PLAN SECRETARIAT, SRI LANKA
Mr. How. Thank you, Mr. Chairman, for the opportunity to
address the committee on harm reduction.
First, allow me to introduce myself and the organization
that I represent. My name is Tay Bian How, the director of the
Drug Advisory Programme of the Colombo Plan.
The Colombo Plan Drug Advisory Programme was established in
1973 as the first regional intergovernmental organization to
address the issue of drugs in Asia and the Pacific region. The
mandate was the task of consulting member countries on the
economic and social implication of drug abuse, particularly
encouraging member countries to establish national drug
secretariates, advising member countries, adopting some
policies, strategies and programs to control the problems
relating to drug abuse and organize training activities to
enhance the human resource development in member countries to
tackle the drug problem. Currently, we have 25 member-countries
spanning the whole of Central Asia, South Asia, Southeast Asia,
East Asia and the Pacific.
The funding of the Colombo Plan comes from voluntary
contributions of member countries. Since its inception, the
Drug Advisory Programme has implemented more than 200
international, regional, and national conferences, seminars and
training programs. More than 6,500 officers from both
governments and NGO's from all member countries have been
trained in the field of supply reduction, law enforcement,
legislation, crime prevention, treatment and rehabilitation.
Among the numerous achievements of the Colombo Plan,
particularly in relation to harm reduction, we are particularly
proud of our work for the past 2 years in Afghanistan, Pakistan
and other predominantly Muslim communities in the region. We
have been supporting Muslim-based antidrug programs, civil
society organizations in Central Asia and South/Southeast Asia
to reduce drug consumption that provides funding for terrorist
organizations and reduce the recruitment base of terrorist
organizations.
The Colombo Plan developed a series of faith-based demand
reduction seminars. In March 2002, in Malaysia, more than 400
Muslim faith-based antidrug programs from Asia and the Middle
East have attended this initial seminar. Since then, the
funding from the U.S. Government has continued the seminar
series throughout Southeast Asia.
As a result of one of these seminars, the Afghan mullahs,
particularly led by the Deputy Minister of Hajj and Agwaf, the
Ministry of Religious Affairs, requested that the Colombo Plan
train all the mullahs in the country. We planned to train about
500 to 800 of their fellow mullahs in Afghanistan this coming
May.
At the second regional seminar just last December,
particularly in Malaysia, also funded by the Malaysian prime
minister's economic department, once again the representative
from the Ministry of Hajj and Augaf requested for the training
and also assistance with establishing drug treatment outreach
centers in their mosques throughout Afghanistan.
Likewise, leading Indonesia mullahs also attended training,
and there are plans to collaborate on providing drug prevention
and outreach services to our mosques and madrassahs in the
country.
The Colombo Plan is also establishing singular outreach
centers in Muslim regions of southern Philippines, southern
Thailand, Malaysia and Pakistan.
With regards to harm reduction, we are very concerned about
these efforts that we are working over the years that certainly
will undermine the achievements of the Colombo Plan. Harm
reduction will undermine the root efforts of the Colombo Plan
over the years.
First, harm reduction, particularly needle exchange
programs are against the national policies of Asian countries.
Many Asian countries are not endorsing harm reductions. In
addition there are not many injecting drug users in the region.
Of all the drug users, they either are doing chasing or not
needle exchange.
For example, in Afghanistan, we introduce a country having
predominantly an opium-smoking problem.
The needle exchange program is introduced and will
certainly increase the incidence of injecting drug abusers
rather than eliminating it. Furthermore, it is against their
religion and is culturally inappropriate.
Due to the constraints of funding it, as has been said by
my colleague, it is sad to see many NGO's are influenced by
this harm reduction movement to embark on such an initiative.
They are influenced by the flow of funds, not the means of such
an initiative in the region. With funding from the harm
reduction movement, the message is disseminated by these NGO's,
actually destroying the very fabric of the Asian society as the
message is not crime and prevention, but actually legalizing
the use of drugs.
In conclusion, no country in the region has actually proven
the incidence of drug use has been reduced with the harm
reduction program and policy. What is actually needed is more
reduction efforts providing prevention and abstinence and
treatment in all our programs in the region, such as the Asian
recovery symposiums, global prevention conferences and Asian
Youth Congresses. None support harm reduction initiatives such
as needle exchange program.
Mr. Souder. Thank you very much for our testimony.
[The prepared statement of Mr. How follows:]
Mr. Souder. Our next witness is Dr. Chris Beyrer of Johns
Hopkins Bloomberg School of Public Health.
STATEMENT OF CHRIS BEYRER, M.D., M.P.H, JOHNS HOPKINS BLOOMBERG
SCHOOL OF PUBLIC HEALTH
Dr. Beyrer. Thank you very much, Chairman Souder, Ranking
Member Cummings and other members of the committee.
I want to thank members of the committee for the
opportunity to speak to you today on an important issue, the
prevention of HIV/AIDS and other blood-borne pathogens, spread
through unsafe, licit and illicit injections. I would like to
thank the members of this subcommittee for their leadership in
bringing attention to the issues before us, including the large
and increasing heroin production in Central Asia, specifically
Afghanistan, and for Chairman Souder's support for democracy in
Burma.
I would also like to ask permission to submit revised
testimony after this hearing. I am an infectious disease
epidemiologist at the Johns Hopkins School of Public Health in
International Health and in epidemiology, working primarily in
international HIV prevention.
I think there's broad agreement that global HIV/AIDS
prevention and control is an important human health and
security concern for our country, the Congress and the Bush
administration. While sexual maternal-infant transmission are
the most important modes in Africa, unsafe injection practices,
primarily of opiates, are the primary risks driving HIV
epidemics across the Russian Federation, Ukraine, Belarus,
northwest and southwest China, northeast India, Vietnam,
Indonesia, Iran, Tajikistan, Uzbekistan, Moldova and several
other states in eastern Europe and the former Soviet Union
today. HIV spread among injecting drug users is an important
component of the global pandemic accounting for an estimated 10
percent of all new infections in 2003, but 30 percent of all
infections outside of Africa.
I want to draw attention to some of the shared features of
these epidemics. First, they have tended to be explosive. HIV
prevalence rose in Bangkok injectors from 2 percent to 40
percent in just 6 months, and we have seen these kind of
explosive epidemics repeated again and again.
They have been transnational. Both China and India have
their highest prevalent zones along their borders with Burma.
That would be Yunnan and Manipur states, respectively. They
have often, but not always, led to further spread among non-
injecting populations, particularly sex partners of IDU, which
is what Eleanor Holmes Norton was referring to, and this has
been documented in Asia and Thailand, India and China.
They have also proven difficult to control, given
government policies toward injection drug use and the very
limited basic HIV prevention measures targeting injectors in
developing countries.
The scientific evidence is compelling that reducing unsafe
injections among drug users has been shown to decrease spread
of HIV, Hepatitis B and Hepatitis C. Research has also
demonstrated that syringe exchange programs do not increase
drug use among participants or their communities. Opitate
substitution therapy with methadone, in addition, has been
extensively documented as effective in reducing opitate use,
needle sharing and reducing HIV prevalence and incidence.
Yet these and other basic measures to prevent HIV spread
and reduce substance use, including humane and medically sound
treatment programs, peer outreach, HIV voluntarily counseling
and testing services and sexual health services, including
condoms, have been limited in their use, reach and coverage. If
we look at the global HIV epidemic today, it's clear that we
are losing the battle to prevent HIV among drug users
internationally. We must ask why.
One reason is that while implementation of basic prevention
services of drug users has lagged, world heroin availability
has increased, largely due to rising production in
Afghanistan--and some of this information I got off the Web
site for this subcommittee. The U.N. Office of Drugs and Crime
reports a 64 percent increase from 2003 to 2004 in poppy
cultivation across Afghanistan, an increase to approximately
4,200 metric tons of opium based last year, that's the UNODC
estimate, which would generate between 400 and 450 metric tons
of heroin.
This growing Afghan heroin production has led to widespread
availability and use of heroin across central Asia and the
former Soviet Union. Culturally and economically diverse
communities, where increased heroin availability has occurred,
have all seen increases in uptick, dependence and subsequent
transitions to injection. This has happened among the Kachin
Baathists of Northern Burma, the Uighur Muslims of Xinjiang
China, urban youth of St. Petersburg, the Tajik people, the
Iranians and in the Ukraine.
While the Karzai government in Afghanistan has made real
commitments to poppy eradication, the history of successful
programs like Thailand's, suggest that poppy eradication and
the cultural development needed for successful substitution
programs takes years to decades and requires sustained
development dollars in technical input.
The bottom line here is that the Afghanistan poppy economy
and its heroin tonnages will be with us for some years if not
decades. Why, then, have we have been so unable to implement
basic prevention for drug users internationally. In the major
opitate production zones and wider affected regions, treatment
and prevention programs for drug use were limited or non-
existent before HIV began spreading in these regions, and this
remains largely the case.
Indeed across the whole of Asia, the only place where
evidence-based heroin treatment, methadone maintenance are
available on demand and to sufficient scale to drug users is
Hong Kong. This is tragic, given the large and growing
international evidence base for success and prevention of HIV
infection and in the middle of this expanding global pandemic.
While the majority of published reports on the efficacy of
these programs have been from the developed world, primarily
western Europe, Australia, North America, there have been
increasing reports of successful programs in Asia, including
Thailand, Nepal, India, Iran, Indonesia and Vietnam. Much of
this work has focused on harm reduction and needle and syringe
exchange, the most basic tools of some of these interventions.
Yet, political problems remain in many countries.
A review of the literature suggests that one of the areas
that has limited this have been the political unpopularity
beyond the prevention community of these prevention efforts.
In sum, given the growing HIV pandemic and the hard truths
we have to face about increasing heroin availability, it's
clear that what is needed is the rapid implementation of any
HIV prevention measures with evidence of efficacy for this
population.
These include increased drug treatment services, methadone
and potentially Buprenorphine, and needle and syringe
exchanges. Needle exchange, in particular, is not incompatible
with abstinence, and can serve as a first key entry point into
other services, including abstinence-based ones. Now is not the
time to limit effective prevention strategies. We need to
implement the basics before moving ahead with discussions of
more politically sensitive approaches, including safe
injectionsites or other forms of substitution or maintenance
therapy. Thank you.
Mr. Souder. Thank you for your testimony.
[The prepared statement of Dr. Beyrer follows:]
Mr. Souder. Next is Yunus Pathi, who is the president of
the Pengasih Treatment Program in Malaysia. Thank you for
coming today.
STATEMENT OF MOHD YUNUS PATHI
Mr. Pathi. Mr. Chairman, thank you for this opportunity to
testify before the committee on harm reduction and demand
reduction programs.
I am the president of the Pengasih Treatment Program, the
largest NGO treatment organization in Malaysia. The Pengasih
program consists of several projects, which I will describe
below are Rumah Pengasih project, primary treatment services.
Rumah Pengasih is a private treatment and rehabilitation center
that is recognized by the government of Malaysia.
Since its establishment in 1993, RP runs its rehabilitation
services based on the peer support system, which stimulates
rectification of belief systems, management of emotions and
confidence building, behavior shaping, building of survival
skills and spiritual guidance.
Residents are admitted on a voluntary basis to undergo the
treatment program for a duration of between 6 to 12 months.
Program activities are organized around an intensive schedule.
Upon achieving a certain level of readiness, residents will
undergo the reintegration program and following this step in
recovery, they are encouraged to enroll with after care self-
help groups. Basically, the RP program is based on the
therapeutic community model of treatment and rehabilitation.
We have also a Sinar Kasih re-entry program. This program
is an extension of the primary treatment given at RP. This
program plays an important role in the personal recovery of
former drug users. It is conducted in a safe environment with
minimum supervision and involves various social activities.
The focus of this project is on the reintegration into
society. The issues stressed are relationships, work ethics,
time and money management, as well as personal security. Here
clients will have an opportunity for job placements or
vocational training.
We have also a drop-in center in Malaysia, which we call
Bakti Kasih, that distributes information on substance abuse
and HIV/AIDS to groups still affected by drug addictions, as
well as those living in the vicinities.
Drop-in centers are located at places near drug dens and
busy streets. To encourage drug users to drop in, we prepare
amenities such as food, drinks, bathroom, newspapers, rest area
and discussion areas. This gives us the opportunity to chat
with them and give advice on how to break away from the
destructive cycle of drug abuse.
The main focus of Bakti Kasih is to reach drug users
infected with HIV. We would like to see them change their
perception toward life and practice healthier lifestyles. They
are encouraged to accept their life with stride and be more
responsible toward others by not spreading the disease.
Bakti Kasih will also approach and help prepare families to
accept their kin who are HIV positive. Staff members are also
involved in awareness campaigns against drug abuse and HIV/AIDS
to all communities throughout Malaysia.
Bakti Kasih provides the following services: a drop-in
center, an HIV/AIDS information center, peer support group,
family support group, social and vocational training, hygiene
and health advisory, referral services, outreach activities,
anonymous help line and counseling. We have also cooperation
international bodies such as the Colombo Plan, U.S. State
Department, United Nations Office on Drugs and Crime, World
Federation of Therapeutic Committees, Japan International
Cooperation Agency, the Global Drug Prevention Network, as well
as for government narcotics bureaus.
In the past years, Pengasih has transferred knowledge to
scores of foreign nationals, mainly from Indonesia, Maldives,
Bangladesh, India, Pakistan, Afghanistan, Pakistan, Sri Lanka,
South Africa, Japan, Korea and some European nations. This
training and assistance focuses on drug treatment and
rehabilitation techniques, spirituality in treatment programs,
drop-in and after care centers, and fear/family support groups.
Sidang Kasih project. This service involves the
establishment of self-help groups for family members and anyone
affected by substance abuse. These self-help groups are
important as they provide the arena for social learning through
active participation and by listening to the experiences from
members of the group.
The key point of self-help groups is the concept of role
models. Group members are not only trained to follow the
examples of others, but also to become role models. The family
spirit of these groups is not only restricted to the duration
of the session, but also extends into their real lives.
Muara hospice provides services to Pengasih members or
former drug users living with HIV/AIDS by assisting them in
receiving proper health care for various ailments.
Clients are provided with a comprehensive range of care and
support services which cover their personal welfare, diet and
medical needs.
Programs, such as group sessions, are organized to provide
counseling and motivation to people living with HIV/AIDS to
accept the terms of their lives and to continue their struggle.
Seruan Kasih Project. This service involves outreach
activities to various target groups, including inmates of Pusat
Serenti, prisoners, students, government servants and other
community members.
Members of Pengasih are often invited to give lectures,
present working papers at seminars, participate in panels,
forums or discussions, and referred to or asked for opinions on
issues related to drug abuse in Malaysia and in other nations.
Needle exchange programs. Pengasih is totally opposed to
harm reduction, needle exchange programs and drug legalization.
We believe that these programs reduce the perception of the
risks and costs of using drugs, increase the availability and
access to harmful drugs and weakens the laws our governments
have against drug trafficking and use.
Needle exchange programs are of particular concern to
Pengasih because of our work with HIV/AIDS clients. The logic
of distributing needles or syringes to drug addicts is very
questionable. I have treated thousands of drug addicts over the
years, and am myself a recovering person. Drug addicts have
very irresponsible life-styles and are not accountable. Once
given a needle, an addict will readily share that needle with
another addict. They do not care whether the needle is given to
them by a needle exchange program or another addict.
Based on what I have personally observed in Asian
countries, needle exchange supporters give away needles for the
sake of giving away needles. They have no idea of the medical
and drug using history of the majority of people to whom they
provide needles. Most of the narcotics addicts in Asia smoke
heroin and opium, they do not inject the drug. Giving out free
needles will only increase the amount of people who inject
drugs, in addition to encouraging further drug use.
Harm reduction and drug treatment. Harm reduction and drug
legalization supporters like to claim that the fight against
drugs has not been won and cannot be won. They often state that
people still take drugs, drugs are widely available, and that
changing that fact is a lost cause. They like to question the
effectiveness of drug treatment programs, claiming that there
are some addicts for whom treatment will never work.
Harm reduction supporters have repeatedly made these claims
in Asia. What is disturbing is that several well-meaning
countries are taken in by this rhetoric, accepting it at face
value when they have never undertaken an assessment of the
effectiveness of demand reduction programs in their own
countries.
This means that many well-meaning countries are making key
policy and program decisions without the necessary scientific
research to back their decisions.
Several evaluation and research studies in my region around
the world, southeast and south Asia, question the harm
reduction myth that treatment is not effective. For instance,
70 percent of all clients successfully complete the full
treatment continuum at my Pengasih program. This study was
conducted in 2002 by the Malaysian Psychological Association
and verified by Danya International, a U.S. research company.
This outstanding success rate has also been documented in
similar programs throughout Asia. At the Pertapis Halfway House
in Singapore, over 70 percent of all clients also successfully
complete the full treatment continuum. The Mithuru-Mithoro
treatment program, run by a Buddhist monk in Sri Lanka, has
evidenced even higher success rates, with 89 percent of all
clients successfully completing the full treatment continuum.
Many Asian NGO's receive their budget from the EU without
knowing the consequences of what they are doing. From my
observations and that of my colleagues in the Asian Federation
of Therapeutic Communities, of which I am the vice president,
we have an increase in the number of people using drugs as a
result of the free needles. AFTC is the largest federation of
drug treatment and rehabilitation programs in Asia.
I need a clarification of U.S. policy.
In Asia, there is some confusion about U.S. Government drug
policy. We in Pengasih agree with the demand reduction approach
that is taught by INL and ONDCP in their demand reduction
seminars in Asia. Pengasih has also trained on the same Colombo
Plan team with Dr. Andrea Barthwell, former deputy for demand
reduction at ONDCP, who is testifying here today. We hear that
the Bush administration does not support needle exchange
programs. In our training with INL, Colombo Plan, and Dr.
Barthwell, we do not support needle exchange programs. But,
some of our colleagues in Asia tell us that needle exchange is
a U.S. Government policy. We tell them that INL and ONDCP say
no, but they tell us that USAID supports and funds needle
exchange programs in their countries. This is causing great
confusion in my region as many people look to the U.S.
Government for guidance on drug issues. As you can see, there
is a need for clarification on U.S. drug policy.
In conclusion, I hope my testimony has been helpful for
this committee. I thank you for the courtesy of inviting me to
participate in this hearing.
Mr. Souder. Thank you for your testimony.
[The prepared statement of Mr. Pathi follows:]
Mr. Souder. Our next witness is Dr. Robert Newman, director
for International Center for Advancement of Addiction Treament,
Continuum Health Partners, Incorporated.
STATEMENT OF ROBERT G. NEWMAN, M.D.
Dr. Newman. Thank you very much, Mr. Chairman, it's a
privilege to be asked to testify before this committee, and let
me say as a health care professional who has devoted his entire
career to enhancing, extending and providing addiction
treatment, I am particularly appreciative of the role that you
have played in advancing the treament with Buprenorphine of
opitate addiction and the role that other fellow members of the
committee have played in other forms of addiction treatment and
harm reduction measures in general.
Let me, at the very outset, answer the question
unequivocally that is posed in the title of this hearing, and
that is that, no, I do not believe there is any such thing as
safe drug abuse. I would hasten to add that safe addiction,
safe drug use, is not, to my knowledge, has never been, the
intent behind any harm reduction efforts in this country or
elsewhere.
The intention of harm reduction efforts is very, very
straightforward. It is to lessen suffering, it is to lessen
illness and it is to lessen deaths. And I would hasten to add
that this is not just an aim of reducing the harm, frequently
the fatal harm, among the users themselves, but also among
people in the general community, because everybody is affected
crime wise, healthwise, by the problem of drug abuse and
everybody deserves to have the risk reduced.
My personal views with regard to harm reduction reflect my
first-hand experience with, first of all, the positive results
of harm reduction in a number of places in the world. First,
beginning at home in New York City in the early 1970's, I
experienced and took part in a massive expansion of addiction
treatment. We had within 2 years an increase of over 50,000
spaces in treatment with methadone and also with drug-free
modalities. And the result was dramatic, in terms of a sharp
decrease in crime, a dramatic decrease in Hepatitis, and a
marked decrease in overdose deaths.
Just a few years later in the mid 1970's, I had the
privilege of being consultant to the government of Hong Kong,
which made a very simple commitment, which I hope some day will
be made by this government as well. And that is that every
single heroin addict in Hong Kong, who was willing to accept
treatment, would get it and get it at once.
Hong Kong achieved the seemingly radical-to-many impossible
goal within a period of 2 years and enrolled over 10,000 people
in their methadone program.
As was true in New York a few years earlier, they
experienced a sharp decline in Hepatitis, in crime, and they
have continued for the past almost 30 years to have treatment
on request a reality to every single person in Hong Kong, and
they publicize--and I have never seen anything similar in this
country in any city in this country--the government of Hong
Kong publicizes that if you or a friend or a loved one has a
problem with heroin addiction, help is available immediately.
That must be the goal.
As a consequence, I am convinced of this success in having
treatment available on request for all who want it and all who
need it. Hong Kong is in the almost unique position of having
virtually no HIV/AIDS transmitted by heroin users, and that is
truly a remarkable achievement.
Finally, back again to the Western World in France in the
mid-1990's, I experienced a commitment also to radically
increase the number of people receiving addiction, treatment,
primarily with Buprenorphine, also with methadone, within just
2 or 3 years they had over 80,000, 80,000 people in France
receiving treatment, who had not received any treatment before,
and they experienced an 80 percent, 80 percent decline in the
overdose rate in the country, which is a remarkable
achievement.
Finally, as a physician, as a public health clinician, but
also somebody trained in clinical medicine, I would like to
express that despite all the controversy over harm reduction,
harm reduction is part and parcel of the concept and the
practice of medicine. It has been for millennia.
Harm reduction, as opposed to cure, is what medicine
overwhelmingly strives for. It strives for this in physical
diseases like diabetes, like arthritis, like hypertension, like
cardiac disease and it strives for harm reduction in primarily
neurological or mental illnesses as well.
There is nothing exceptional in aiming for harm reduction.
What could be more self-evident than reducing suffering illness
and deaths among people who have a chronic medical illness. We
know it can be done, because it's been done in this country and
elsewhere, knowing it can be done gives all of us an obligation
the pursue that goal, and I certainly hope that will be the
agenda of this Government.
Thank you very much.
[The prepared statement of Dr. Newman follows:]
Mr. Souder. Thank you. And our last witness on this panel
is Dr. Syahrizal Syarif. Maybe you can say it more clearly for
me, from the Colombo Plan in Indonesia.
STATEMENT OF SYAHRIZAL SYARIF
Mr. Syarif. Thank you, Mr. Chairman.
First off, I would like to thank you for the opportunity to
come and testify in this hearing today. I am Syahrizal Syarif
representing Nahdatul Ulama. Nahdatul Ulama is the largest
Muslim organization in Indonesia, and might be in the world,
with members around 60 million. As I mentioned, I come along
with the Colombo Plan group. As a member of the largest
religious organization, we are dedicated to support the
community in Indonesia to responsibility and harmony.
We are very concerned about drug addiction program. Right
now in Indonesia, we have the drug abuse, drug addiction, but
also a student in our Islamic boarding school. We have 1,000
Islamic boarding schools around the country. Also affected with
this problem.
Right now, we have, we already, with the Colombo Plan, we
already are attending the training workshop and then preparing
for the program in Ceta Chalice Islamic boarding school in
Indonesia.
Regarding harm reduction, I will just give this brief
testimony, regarding the harm reduction approach. We are
certainly, and base Islamic perspective, that is mentioned very
clearly by my colleagues from Malaysia. We cannot accept such
an approach.
For us, it is certainly like, we are supporting the use of
substance abuse. And in another perspective, also, we consider
that the solution to the solution is not certainly is only
based on the scientific base, but we have to consider our
culture and belief and also the principle of public health,
this approach looks like it is against the principal of
priority and fairness and equity. You know, in Indonesia, we
struggle with communicable disease and also right now we
struggle with the recovery and rehabilitation of post tsunami
in Aceh.
We would not spend in certainly such an approach. We spend
more to prevention program rather than recovery program.
I think that in conclusion, please consider the
susceptibility based on that, also consider about cultural and
also relief in Indonesia.
Thank you.
Mr. Souder. Thank you very much. I know, Dr. Bensinger, you
are very close to making your plane. Do you have any closing
comment? And then we will excuse you from your panel.
Mr. Bensinger. Chairman Souder, I was impressed by the
testimony that we all heard. I would only encourage the
Congress to reflect on the basic obligations that we have to
follow the science and follow the law. And Dr. Newman's
comments, I thought, as well as those of the colleagues from
overseas, are most pertinent. Treatment can work, it does work.
The idea of continuing someone's addiction by providing needles
is contrary to science, contrary to the opportunity of
diverting someone into treatment and contrary to our
obligations as a Nation with other nations, to abide by the
laws.
Thank you, Mr. Chairman.
Mr. Souder. Thank you.
Ms. Watson. Mr. Chairman.
Mr. Souder. Mr. Cummings had a question for Dr. Bensinger.
Mr. Cummings. Doctor, I know you have to go and I just want
to get this quick question in. As I listened to Dr. Newman's
testimony, what happens, Doctor, when you don't have treatment?
Sufficient treatment, when you have a situation where there is
not enough money provided for treatment, and, I mean, I am just
curious, in light of what Dr. Newman was just talking about.
And he also said something very interesting about how
medicine in and of itself depends upon or one of the biggest--
one of the things that they base some of their medical
decisions on is reduction of harm, and that it's not something
that is new. Nobody wants--it is upsetting to think that people
want folks to stay addicted. That's the last thing we want. But
at the same time, we want to reduce some harm. But we make the
assumption, almost, that, you know, the treatment is there, and
I am just here to tell you, as Dr. Beilenson will testify a
little later on, it's not always there.
Mr. Bensinger. Congressman, I want to answer your question.
But let me correct the reference to doctor, which is one of an
honorary title. My doctorate was not earned in a medical school
like my colleagues, but bestowed upon me by a couple of foreign
governments whose arms were twisted by DEA agents that wanted
me to feel good.
But I think you asked the right question, because I think
treatment when you need it is what we need. When someone who is
addicted can't get it, they are going to have pain, they are
going to have suffering. They are going to not be right with
themselves or other people. So I think one of the objectives is
to have a network that could provide, as Hong Kong did, and
some cities can do, but not many, a way for people to get help.
Mr. Souder. Ms. Watson, did you have a question for Dr.
Bensinger?
Ms. Watson. I had a question possibly to you about the
ongoing panel, because as I read the title of this hearing
today, harm reduction or harm maintenance, I found much of the
testimony irrevelevant to the situations which we are battling
here in this country. I wanted to speak to needle exchange as a
public health issue.
So my question to you, Mr. Chair, will we be able to do
that with panel two? I don't think much of the testimony from
panel one was relevant to the situations that we confront in
our respective districts.
Mr. Souder. If people disrupt a congressional hearing, they
are subject to removal from the room.
Ms. Watson. Right. To the policies that we will have input
on. I don't know if there is a proposal for safe injection
facilities in front of this Congress. So can you answer those
two questions.
Mr. Souder. First----
Ms. Watson. Will panel two give us more relevant
information and relevant to the title of this hearing, and is
there such a proposal in front of us?
Mr. Souder. First, Doctor, I think you could feel free to
head to the airport. You will miss your plane.
Ms. Watson. I didn't hear.
Mr. Souder. I am releasing him to make his plane.
First off, harm reduction and harm maintenance is
predominantly at this point an international issue, not a
domestic issue, and we are, in fact, doing both.
Ms. Watson. Excuse me, for the----
Mr. Souder. Ma'am. I am the chairman of the subcommittee,
and you ask a question. The primary answer to your question is,
yes, we are dealing with this some at the domestic level, but
we have funding bills in front of us regarding aid
internationally and what we are doing to many nations around
the world is against their culture. We also have domestic
concerns.
Ms. Watson. That's not an answer to my question.
Mr. Souder. And that most of the funding program, most of
the programs around the world where we can see whether they
work or not are international.
Ms. Watson. Simple question, and you don't have to spend,
you know, your time. Will panel two be able to answer questions
about domestic, before----
Mr. Souder. Well, obviously, Dr. Newman, who is a minority
witness has worked with domestic, and I believe probably Dr.
Beyrer has worked both domestic and international. Those who
have come all the way from Malaysia and from Sri Lanka and
Indonesia obviously don't know domestic. On the second panel, I
believe every single witness is domestic.
Ms. Watson. Thank you, you answered my question.
Now, I am going to start my round of questioning. Yes, you
can head out.
Mr. Bensinger. Are there more questions for me?
Mr. Souder. No, I don't believe so. I wanted to first--each
of our international participants can answer this question. But
with Dr. Syarif, Indonesia is the largest Muslim country in the
world, and part of the challenge here is, as we try to
communicate a message that drug abuse is wrong, which is not an
easy message to communicate, especially in Afghanistan, in the
Golden Triangle area, as it spreads to Malaysia and each of the
countries here.
And when the American Government comes in with an approach
while you are trying to communicate that drug abuse is wrong
and trying to handle the treatment question in a way, when our
government comes in with a mixed message, as we heard in this
hearing, how does this play through in your countries and what
is the reaction to our government, in and of itself to our
message against narcotics? Kind of give me a reaction of how
people from your nations look at us as a Judeo-Christian
heritage country, but largely a secular nation, at this point,
coming in to a Muslim nation and telling you how to do it.
Dr. Syarif. Yes. I think--I don't know your impression
about that. But as I mentioned 3 months ago, we sent 24 Ulama
to attend the training workshop in Malasia. After the workshop,
all of the Ulama realized that this is very important, a very
important issue, and then realized that Basantan and Ulama have
the important role to involve and do something in this issue. I
think we are all very open with cooperation and the idea of the
intervention.
First about harm reduction. You know, it seems to us, we
localize the--it is like we localize the--localize the workers,
sex workers, something like that, and we cannot accept
something like this. We cannot change the good--the big scene
with the rest--seeing--without seeing something like that.
Based on our belief and our faith, it is certainly not
acceptable. But we are open to discussion. I think it is no
problem.
Mr. Souder. I think, Mr. How, that as you work in your
program in Afghanistan, which has seen this huge surge in
heroin production, which can't possibly be absorbed in the
market, so probably there will be a reduction in production for
a couple of years, because this is just something we have never
seen before. As this starts to spread into central Asia and
into Europe and around the world, how do you see we are going
to be able to tackle the mixed message?
Mr. How. Mr. Chairman, yes, in Afghanistan, I have seen not
just able men being affected by drug abuse, but I have seen
woman, even though in the burkas and all covered up, and also
young infants as young as babies 1 or 2 years old using opium.
The women have to keep them quiet, keep the babies quiet while
they are at work earning a living.
The point is, they are all opium smoking, not injecting
drug users. They are not IV drug users. They need treatment.
Certainly, there are no treatment services around Afghanistan,
with the exception of one or two facilities being operated with
the help of United Nations and also funded by British here and
there. They have one or two, but not enough. That is why the
Colombo Plan, with the assistance from the U.S. Government is
starting. I mean, we are starting to mobilize.
As you know, the religious leaders, the mullahs, command
considerable respect in Afghanistan. They have a say in most of
the policies in Afghanistan. They are certainly opposed. When
we do training in Colombo recently, they actually treat drug
addiction as, like a crime. They don't say it's a disease or
it's a grave disease, but after 1 week they accept it. They
accept it. We can help them. Drug addicts are not criminal,
they are patients, they are sick people, and they are not
criminals, and we don't need to give them lashes or whatever,
so they can be treated.
What I feel is there should be no more treatment programs
going in Afghanistan and mobilizing the religious leaders,
where by using spirituality, where by it is very powerful in
Afghanistan, to provide those services, either prevention or
treatment services. That will be the way to go, not providing
them needles. How can a young person, 1 or 2-year-old, without
knowing anything, now you have needles going around, and just
like saying, doing drugs through needles is OK. I mean, that's
not the message. It is certainly very confusing to the young
people.
We have also seen one instance, a young person, a youth,
distributing needles to another group of youth to say if you
are using drugs, don't share needles. That is not the message.
You should do primary prevention, primary prevention should be
the main strategy as, in your world, strategy as in many
strategies of Asia, Asia, Malaysia, the main strategy is
prevention, that is the strategy it should be.
Thank you.
Mr. Souder. Let me go to Mr. Cummings for questions.
Mr. Cummings. Yes. Thank you very much, Mr. Chairman. As I
was sitting here, I was trying to--I was just listening to the
witnesses very carefully and trying to see what threads ran
through their testimony to try to get a feel for what might be
the basis of their positions.
One seems to be religion. Certainly as a son of two
preachers, I have a lot of respect for religion. I am just
wondering, Dr. Syarif, I think you and Dr. Bahari talked about
the Muslim faith, and how the use of drugs, and I think you
just mentioned it, Dr. How, the use of drugs as seen--I guess,
as a sin.
Mr. Syarif. That would be correct.
Mr. Cummings. A little louder for me, please.
Mr. How. Yes, as a sin, yes.
Mr. Syarif. Yes.
Mr. Cummings. So as a respecter of religion, then it would
seem as if anything other than getting the person off of the
drug so that they can live a sinless life with regard to drugs,
that is, it seems to me that would be about the only thing that
would be acceptable from a religious standpoint. Does that make
sense?
Mr. Bahari. Yes.
Mr. Syarif. Yes.
Mr. Souder. So that means that you would be against things
like this, harm reduction and things like needle exchange
because they fly in the opposite direction, the religious
teachings and believes; is that right?
Mr. Bahari. Yes.
Mr. Syarif. Yes.
Mr. Cummings. Going to you, Dr. Newman, you were talking
about how harm reduction is a part of medicine. And I can
remember, as Dr. Beilenson, I am sure will remember, there was
a time in Baltimore where there was a question as to whether or
not you would have clinics for young girls and be providing
them with information with regard to contraception.
And the religious community jumped up, they were very
upset, and they said that they would be encouraging,
encouraging young girls to become involved sexually at an
early, young age. We hear that argument all the time. The
problem with that is that the young people would come to me and
say Congressman, I mean, you can say what you want, we are
already doing that.
And so what we need--and, believe me, nobody likes to hear
that, as a father of two daughters. I don't want to hear a 14-
year-old say that they are already active. But, at the same
time, I can either be practical, and watch my teenage pregnancy
rates go up--or not to be practical and watch them go down, or
I can just base everything on my beliefs and say you are a bad
girl and then the next thing you know I have a high teenage
pregnancy rate. In Baltimore, I am glad to say that we have
seen our rate go down.
Is it somewhat similar, Doctor?
Dr. Newman. Yes, sir, I think you are absolutely right. I
think we have to accept the reality that today there are a
great many IV heroin users in virtually every city in America,
and despite the best efforts of many Congressmen, including
some of the people on this committee, some 80 percent of all
the IV heroin users in America have no access to treatment.
That is a scandal.
That is a shame, and in the face of this huge proportion
without treatment, to say and we are not going to make it more
likely that they will survive until someday they can get
treatment, I just don't understand that. It's a question of
abandonment, abandonment of the roughly 80 percent who have no
access to treatment, or saying at least we are going to try to
help you survive until we, government hospitals, doctors, get
our act together and make treatment available for you.
Mr. Cummings. Do you see the--I think Dr. How was saying
that in 1 week, for an addict--if an addict first comes
forward, they see it as criminal basically and then after about
a week, they see it as a----
Mr. How. Disease.
Mr. Cummings. I mean, a health situation. Dr. Beyrer, I
mean what have you seen, have you seen it in your studies? You
said you had been in quite a few locations. Is that usually the
case that you see it, or do you see them treating it as a
health situation overseas?
Mr. Beyrer. Well, I would say one or two things. First of
all I think that----
Mr. Cummings. Keep your voice up, please.
Mr. Beyrer. Yes, sorry. I think it's true, generally, that
there's been a great deal of diversity in approaches to the way
addiction has been handled, but we have to be mindful of how
recent the epidemics in many of these countries have heroin
use, heroin availability and injection drug use.
Many countries are dealing with really newly emergent
problems in this area and with newly emergent HIV epidemics,
and we have seen a great deal of stigma around both HIV
injection and injection drug use that unfortunately has a
negative impact both on getting people into treatment and on
being able to deal with HIV infection.
Now, I would just give you an example, one of the countries
where we have a project under way, Tajikistan, we just did a
small collaborative study trying to do some outreach to
injectors and get a sense of how serious the problem was, how
many injectors there were. We had good support from the
government there to do this initial work.
We doubled the reported number of HIV infections just by
assessing HIV infection in 500 users, because this is an
epidemic that really has not been studied. It is happening as
we speak. It may have doubled again in the last couple of
months. And folks there.
Mr. Cummings. Wait a minute. I just want to make sure we
are clear. When you say you double, you mean you had some
numbers that you started with with an assumption, and then you
found out that there were a lot more than----
Mr. Beyrer. That's right.
Mr. Cummings. I didn't want that recorded that because of
your efforts, you doubled.
Mr. Beyrer. That's not the plan. Thank you for that
clarification. I want to make one other point very clear, which
is that what is being exported to Tajikistan from Afghanistan
is not opium, it's heroin, and we have heard a lot of
discussion here about the fact that opium is what is smoked and
opium is what is around.
On the ground in central Asia, what is moving out of
Afghanistan and moving through Russia is heroin, and that's why
the countries I listed in my testimony are having explosive
epidemics of HIV and drug users.
Mr. Souder. That's an incorrect statement, by the way.
Opium base is moving, heroin base does not move out of
Afghanistan.
Mr. Cummings. Can you--I'm sorry, Mr. Chairman, I didn't
hear that. You shook your head, you said something, I don't
know what you all did.
Mr. Souder. Heroin is a process.
Mr. Cummings. Right.
Mr. Souder. It is like opium poppy turns to paste and the
paste is what is distributed out of Afghanistan. They don't
have heroin labs to process heroin. Then when it gets to maybe
a city like Bangkok or somewhere along the line, it is being
converted to heroin.
Mr. Cummings. Yes. That was interesting.
Mr. Souder. That was an incorrect statement.
Mr. Cummings. OK, I just had one last thing. There have
been several statements here, and I am sure we will get into
this in the second panel, that a person, Dr. Newman, who goes
to a needle exchange because they are so desperate for drugs
and because their state of mind and because they are an addict,
that they might not have the wherewithal or even care about
exchanging a clean needle, a dirty needle for a clean one.
I mean, have you seen--I mean, from what you--your
knowledge. I don't know whether you have a base of knowledge on
that or not.
Dr. Newman. I do, sir, I have always been struck by so
many--can't quantify it, but so many IV drug users care so much
and that's why they go to needle exchange. If they didn't care,
I mean, they don't go there with free coffee. They don't go
there to chat with friends. They go there for sterile needles
that they know will increase the likelihood that they will
survive. They vote with their feet and not to make a service
available that we know will improve their chances of survival.
I just can't understand that position.
Mr. Cummings. Thank you, Mr. Chairman.
Mr. Souder. Mr. McHenry.
Mr. McHenry. Thank you, Mr. Chairman, for having this
hearing today. I think it's certainly important to bring this
to the public's attention. It's certainly been eye-opening for
me as a new member of this committee to have such an education.
I certainly appreciate the panel for all of you traveling so
far to be here today.
I have a couple of questions, general questions, first of
all. Harm maintenance. I think Dr. Newman said this is sort of
a fundamental tenet of medicine is sort of harm maintenance.
Dr. Newman. No, sir, I most certainly did not. If I gave
that impression, I am not sure how. But nobody, nobody in their
right mind would advocate maintaining harm. Harm reduction is
the antithesis.
Mr. McHenry. Harm reduction, certainly, certainly. Harm
reduction. OK, my apologies, because we are talking about both
harm reduction and harm maintenance. My apologies. Sorry, sir.
Certainly, but I do have actually a couple of questions for you
about a book that one of your organizations put out that you
are on the board of.
This sort of goes hand in hand with this policy. And it's
called, ``It's Just a Plant.'' A children's story about
marijuana, certainly a nice little book. It's really a shame
that Representative Waxman is not here. He has been one of the
chief opponents of the tobacco industry in Congress, and really
lampooned them, as justly as I believe it is, using cartoon
characters to spread smoking in children. Well, this is a whole
book geared to children and it explains marijuana to them.
I would not say in discouraging fashion, in fact, rather
encouraging, which is absolutely the opposite, I would say, of
harm reduction. This would be harm production, I would say.
I would just question your organization. Maybe your defense
of this book and what type of message this sends.
Because I think this relates to this overall question of
sort of maintaining drug use through needle exchange programs
and things of that sort, and I think it's a rather harmful set
of circumstances for us to be dealing with. So if you could
address that.
Dr. Newman. Sure, I will try. Let me say that I am among
the very, very few people I know who can say under oath that he
knows absolutely nothing about marijuana.
Maybe it's shameful, but I have never read that book, which
is part of the reason why I don't even have any academic
knowledge, let alone any first-hand knowledge. So I just can't
comment on the book, because I just know nothing about it,
either the topic or the particular publication.
Mr. McHenry. OK, are you on the Drug Policy Alliance board.
Dr. Newman. Yes, sir, I am.
Mr. McHenry. You are, OK, OK. Because as I understand it,
this was funded through the generous support of your
organization as well as George Soros and many others sort of in
the pro-drug community, and I do think it's a rather disturbing
book to see distributed widely and to see you on a
congressional panel representing, as part of this group, it's
just really disturbing to me.
Dr. Newman. Could I just respond to that, just to say that
I have a very special area of expertise and interest. I do not
pretend to speak for the Drug Policy Alliance. I do not edit
the products of that organization or any group that they fund.
It's just not something that I have any involvement in
whatsoever. I can neither defend nor condemn.
Mr. McHenry. So, how long have you been a board member, if
you don't mind me asking.
Dr. Newman. According to the chairman's reminding me,
apparently since 1997.
Mr. McHenry. Well, I would just say that perhaps you might
want to look into the organization you are part of. That might
be a positive thing, so that when I ask questions like this,
you will be able to answer them in the future if you are before
another congressional committee.
Audience Member. Hey, buddy, why don't you go smoke a joint
and relax?
Mr. McHenry. Well, thank you, sir. Smoke another, buddy.
Audience Member. Thank you, I will, sir, thank you very
much.
Mr. Souder. In a congressional hearing, we are supposed to
have a decorum, and I am disappointed we are dealing with that
today. Now I would like to yield, Mrs. Norton.
Ms. Norton. Mr. Chairman, I'm sorry I was not here for much
of the testimony so I will pass.
Mr. Souder. Ms. Watson.
Ms. Watson. I have no more questions for this panel, but I
do have a statement. I was chair of the California Health
Committee and the Senate for 17 years, when I was a legislator.
And I held hearings up and down the State of California, the
largest State in the Union, on public health issues. And one of
the things that I learned by being out there in the community
is that people indeed were injecting drugs into their systems.
And through the injection of drugs, AIDS was spreading when
unsuspecting partners had sex. We studied for years to try to
see what we could do to increase the harm and the risk from
needles being used over and over again.
One of the things we learned from San Francisco is that if
you took a dirty drug and gave a clean drug, needle, excuse me,
that you would then remove the instrument of contamination out
of exchange. You could not get a clean needle unless you gave a
used needle.
At that point of contact, you were not given the drugs, you
were just given clean works, and, once we identified you, we
could then tell you about optional treatment programs that were
available to you by the County Health Department. I carried
that bill for 8 years before it was passed into law, because
our studies in the State of California, and I don't know about
all the other countries and their programs, I heard a little
bit about them today, what I am interested in learning what
works and what doesn't work from a public health standpoint.
I do not promote drug usage. I don't want anyone to speak
for me. I can speak for myself. What I am promoting is reducing
risk in communities, addressing the problems head on, trying to
help people become responsible for their own healthcare and
reducing addiction. So, Mr. Chairman, I am looking forward to
the next panel who might be able to offer some insight. But I
see that I am already late for a very, very important hearing
elsewhere. Thank you very much.
Mr. Souder. Thank you. Representative Davis.
Mr. Davis of Illinois. Thank you very much, Mr. Chairman,
and as a part of my time, I am going to read a letter that I
received from a group in my congressional district at Roosevelt
University. It says here,
Chairman and members of the subcommittee, it has come to
our attention that on February 16th, the House Government
Reform Subcommittee on Criminal Justice, Drug Policy, and Human
Resources will be holding a hearing entitled, ``Harm Reduction
or Harm Maintenance: Is There Such a Thing as Safe Drug
Abuse?''
The title alone suggests a predetermined judgment about
harm reduction practices. Our hope is to demonstrate that harm
reduction philosophy by no means advocates drug abuse. Our
group, Students for Sensible Drug Policy, strives to achieve
sustainable policies that foster civil rights, health and
safety. One of our goals is to support harm reduction
activities, ranking from encouraging designated drivers to safe
distribution of health-related suppliers.
Some members of the committee may have been presented with
a misrepresentation of harm reduction practices. To us, harm
reduction means making sure that no one dies in a drunk driving
accident because we were afraid to address the harms associated
with drinking and driving. To us, it also means that no one
should die from blood-borne pathogens just because they suffer
from the disease of addiction.
Harm reduction embraces abstinence, but only providing
programs that have abstinence as the immediate goal does not
acknowledge the cycle of addicted disorders. These disorders
nearly always require relapse in order to be abstinent. Harm
reduction allows addicted people to be engaged in the recovery
process, even if they cannot immediately be abstinent.
Abstinence is a long-term goal. Harm reduction is the short-
term process.
Mainstream 12-step programs are known for never turning
away an addict that wants help but cannot stay clean. We, too,
embrace this idea and believe that it is the core of harm
reduction. Our belief is based on research, is that there is no
single treatment modality that works for everyone. Our hope is
that harm reduction will continue to be a choice in a range of
treatment options for those who desire treatment.
Sincerely, Students for Sensible Drug Policy, Roosevelt
University chapter, 430 South Michigan Avenue, Chicago,
Illinois; Students for Sensible Drug Policy, National Office,
Washington, DC, and the Midwest Harm Reduction Institute, 4750
North Sheridan Road, Room 500, Chicago, Illinois.
And Mr. Chairman, I would ask unanimous consent that this
letter be inserted into the record as a part of the hearings.
[The information referred to follows:]
Mr. Davis of Illinois. My question is to Dr. Newman.
Dr. Newman, I have been involved in promoting something
that we call Drug Treatment on Demand. And we were fortunate to
get a referendum put on the November ballot in Cook County,
which is the second largest county in the United States of
America with more than 5 million people. And we asked the
question, should there be drug treatment on demand? 1.2 million
people voted in the affirmative in terms of saying yes; 177,000
voted against the referendum. My question is, is there a time
when treatment is most effective in terms of drug treatment and
its impact and effectiveness of treatment?
Dr. Newman. First, I would say those 1.2 million people
were absolutely correct. In response to your specific question,
what is the right time, it is any time that one can engage a
drug user who wants help. And let me say that you should take
heart in the fact that we know it is possible to achieve the
goal of treatment on request regardless of the amount of
resources available. It has been done in Hong Kong. It was very
briefly possible in New York City in the mid-1970's. It has
been possible in France. So I encourage you to lead the charge
of those 1.2 million and pursue a goal that will save countless
lives and suffering.
Mr. Souder. Ms. Norton.
Ms. Norton. Thank you for your indulgence. Just a couple of
questions, because I would like to clarify for the record what
I think may be some confusion that results in the use of the
notion of harm reduction and some confusion between
legalization of drugs and those who try approaches designed to
lure people off of drugs and to keep people from spreading
disease through injection. And I would like to ask just to
clarify for the record Dr. Beyrer and Dr. Newman, do you
believe in the legalization of drugs? Is that your position or
the position of your organizations?
Dr. Beyrer. That is certainly not my position. I think in
my comments, I made the point near the end that harm reduction,
particularly the outreach education components to drug users
have, in fact, been shown to reduce drug use, which certainly
is a goal, and that harm reduction is not inconsistent with the
goals of abstinence. It doesn't have to be inconsistent with
abstinence at all. And I think studies of methadone maintenance
show that it has been able to reduce substance abuse. And I
would thank you for the opportunity to make clear that
legalization of drugs is not a public health position, I don't
think in mainstream public health and it certainly isn't a
personal opinion of mine.
Dr. Newman. I have been in this field for 35 years,
practicing and advocating harm reduction. I have never
advocated legalization. Part of the reason for that is, I don't
even know how it's defined. I have certainly never been for it.
And I'm glad to have the opportunity to clarify.
Ms. Norton. There are people even in this country who
believe, for example, that heroin maintenance for some people
is what you have to do, because they've been addicted for so
long, and of course, that would condemn whole sections of
society to everlasting heroin craving.
One final question, Mr. Chairman. Mr. Chairman, I referred
to your remarks, because my impression in working with you has
been that you are careful about overstating. And I want to ask
these two witnesses again, because a sentence or two in your
remarks go so counter to my own personal experience. For
example, with private parties that do needle exchange in the
District of Columbia, I'm told that very hard core addicts who
have engaged in needles and injection drug use for years are
beyond their reach except often by having them come to get a
needle where they also get some kind of counseling or the kind
that would be totally unavailable to them or they would at
least be unavailable to us. And they tell me about instances
where finally someone who comes to pick up his needle gets
convinced that he should, in fact, go to a drug abuse center
that he would have never gone to by himself.
I want to know if you know, of people described by the
chairman in his remarks, ``harm reduction is an ideological
position that assumes certain individuals are incapable of
making healthy decisions. Advocates of this position hold a
dangerous behavior such as drug abuse therefore simply must be
accepted by society, and those who choose such lifestyles or
who become trapped in them from being able to continue these
behaviors in a manner less harmful to others.'' I'm searching
for the advocates of this position. And perhaps you who are in
the field know of advocates of this position, or do you know of
advocates of this position?
Dr. Newman. I absolutely do not hold that position, nor in
the 35 years that I have been in this field, do I know anybody
who has advocated what you have just quoted from that letter.
Dr. Beyrer. I would concur. And I would reiterate that I
think one of the issues that we need to remain clear about is
when we talk, for example, about needle exchange--and the
representative was so clear about the exchange component, about
getting dirty needles out of circulation, that what we are
trying to do is reach people where they are and reduce the risk
of fatal infectious diseases, which are spreading rapidly,
globally through this route. But this is a key entry point into
treatment, into counseling and into, indeed, getting drug-free
and abstinence.
That is one of the real benefits of needle and syringe
exchanges is that they are an entry into treatment. And I think
as a dual-use, as an entry point into treatment and as an
opportunity to prevent the spread of HIV-AIDS that they have
important public health functions.
Ms. Norton. Thank you.
Mr. Souder. Dr. Beyrer, do you believe in the
decriminalization of marijuana? Yes or no?
Dr. Beyrer. I don't personally have an opinion on that.
Mr. Souder. You are not opposed to it.
Dr. Newman, do you believe in the decriminalization?
Dr. Newman. Marijuana is a drug/medication with which I
have no experience, and I have no basis for an opinion.
Mr. Souder. So on the drug policy lancet on your board, it
says one of the primary goals or the major goals of your
organization is to end the war on drugs, do you agree with
that?
Dr. Newman. I just don't have the knowledge to either agree
or disagree. I don't endorse everything that the organization
says. And on this particular point, I don't have a position
either for it or against it.
Mr. Souder. I think that alone speaks volumes, not to have
a position. It's one thing to say, I don't believe in
legalization. But if you don't believe in any enforcement, that
is, in fact, back-door legalization. Now, how we do it and
what's the most effective way to do it and whether you support
it--and I think your record shows you favor--you focused on the
treatment side, the fact is that I believe you have to have it
all, prevention, treatment, interdiction and enforcement. And
you have legalization. Part of my concern in my statement is
that you really are faced with two choices here, in particular
Dr. Newman, and that is when you are on the board of
organizations that advocate, at the very least, not controlling
the drugs aggressively and often advocating for legalization--
and Congressman Davis, Students for a Sensible Drug Policy
favors legalization.
They have been in front of this committee and have promoted
multiple things for drug legalization. And when you affiliate
anything with the harm-reduction movement with groups that
advocate broader drug agendas, it does call into question which
is driving which. And that is what I believe my statement was
trying to reflect, not necessarily each individual. But you
need to, very carefully, if you want to have credibility on the
Hill and with most Americans, disassociate treatment efforts
for things that are aimed at treatment.
Let me get back to the title of this hearing: ``Harm
Reduction and Harm Maintenance: Is There Such a Thing as Safe
Drug Abuse?'' We have some difference of opinion. I believe
that, whether providing heroin and heroin needles in these
different programs around the United States and around the
world have slightly different mixes with this, but, for
example, in Switzerland, which has been the No. 1 international
model, they provide the heroin and the needle. That is clearly
drug abuse. Whether the goal is for the harm reduction part is
for the people who aren't using the heroin, in other words, the
argument is, as we maintain them in a controlled environment to
go out and work and there is a reduction to the society. It is
harm maintenance to the individual. They are still on heroin.
They are controlling it.
In Vancouver, which is the biggest international model on
needle exchange--I visited there multiple times--it's
expanding, and it's evident to the eyes that it's expanding.
They have multiple locations around the city. They are now
looking going into the suburbs. The argument is that people are
coming in from other parts of the country. It is hard to sort
the data out in Vancouver. But the bottom line is there aren't
swaps for needles. They are coming in because they are free,
and it is convenient, and they shoot up right on the spot. And
there is no control over that.
And in Holland, as we have looked at the programs there,
they haven't worked very successfully. And in Denmark, they are
going the other direction, as is Holland gradually. And I would
argue that this is, in fact, an accurate title.
We can dispute the HIV component is a very difficult
question, because HIV and drug questions are interrelated here,
and the problem is interrelated. In trying to address one, do
we exacerbate the other. That is part of what the debate is.
And as we go international, that is part of our challenge
particularly as we hit other cultures where we are fighting
culture. I want to thank all of our visitors.
Ms. Norton. Mr. Chairman, could I make one remark, because,
again, we have a wholesale term here, decriminalization, being
used. That also hides a multitude of--since I am leery of any
decriminalization, frankly, because small amounts of marijuana
in communities that are prone to addiction can become havens
for large amounts.
But there is a distinction between people who would like to
decriminalize marijuana abuse for very small amounts of
marijuana, where someone gets a record as an 18-year-old, from
people who are engaged in frequent marijuana use. And they
shouldn't all be lumped together as well. And I would like to
draw to the attention of the committee that entire States now
are using diversion techniques for first-time abusers.
They arrest people for drug abuse. This has proved so
counterproductive and weaning people away from drugs has been
so costly that entire States--I understand Jersey would like to
do it, that California would like to do it, that anybody who
gets arrested as a first-time drug abuser is offered treatment
and diverted from the criminal justice system. I do think that
says something about modern methods of trying to prevent and
control the spread of drug abuse.
Mr. Cummings. Mr. Chairman, I think we have to be very
careful when talking about harm reduction. You know, because we
can put out the word that trying to save a life, as Dr. Newman
said, until we can get to a point of treatment, and we can say
there is something awfully wrong with that, but are you saving
a life or lives? In my church in Baltimore, over 10,000 people,
one of our problems has been men who go to prison or have been
involved in the drug world. They get clean, and part of getting
clean is coming back to the church, coming to a church. They
don't tell these young women, who never touched an illegal
drug, have not been involved in risky behavior, none of that,
next thing we know, that young lady has HIV-AIDS. And so I
think, you know, again, we are not living in a perfect world.
Perhaps if it were a perfect world, nobody would be on drugs.
Even if it was perfect with people on drugs, we would have
treatment for everyone that wanted treatment, but we are not
there yet.
And God knows, I hope we get there, because I don't think
that the people--a lot of the people who find themselves on
drugs, wish they never made that first decision, but then they
get stuck in a world that they can't get off the merry-go-
round.
I want to thank all of our panelists for being with us
today, and I do appreciate your testimony.
Mr. Souder. I want to finish my statement.
I believe all minority members have spoken multiple times,
and I want to finish my statement with this panel. I wanted to
clarify something else Dr. Newman said in his testimony. I
believe there is a difference between allowing doctors to
prescribe legal, controlled medication to reduce pain and/or
problems and to try to get people better, and maintaining an
illegal narcotic, with which its only benefit is harm and that
even drugs that are harmful have components in them that can be
isolated.
But to refer to medicinal marijuana or heroin as doing harm
reduction, I believe is a totally different thing than when we
have an FDA controlled drug, not smoked, no basic risk and the
goal is to improve someone's health as opposed to comparing
that to methadone or heroin maintenance programs. It's a
different ball game. Obviously, there is a middle ground here
with pseudoephedrine, a key ingredient in many cold
medications, and yet it is the key ingredient in meth
production. So we are having to figure out how we balance those
two things in our society. We are also having to deal with it
in this committee.
The fact is that legal drugs prescribed by doctors are now
the No. 1 death from drug abuse in the United States, more than
everything else. And that the argument that it should go
through a doctor, or it's doing maintenance or that type of
stuff is increasingly coming into question even in the
controlled limited experiments as we see the destruction that
comes from addiction.
I want to conclude with this, on this panel, regarding
those who came from overseas, particularly what Mr. Pathi said.
You heard that ONDCP has one position, and the DEA, and USAID
has been funding other positions. And I want to clarify
something for the record. This is democracy. You are seeing it
at its best. We don't agree with the Drug Policy Committee, and
we don't agree here. But there is a majority in the minority.
And what has passed in the U.S. Congress is that government
funds can't be used for heroin needles. Government funds can't
be used for these types of programs. If USAID is funding these,
that is why we have all this data coming in. And there is a
disagreement in the United States over whether this should be
the case.
We will continue to debate that. There is a disagreement
over what private funding can do. But the clear majority in
Congress every time we voted has voted against these programs
being done with any taxpayer dollars, that it is an extra
complicated question. And we are going to deal with that with
the second panel, and that is how we deal with this in an
international arena where the United States is being seen as a
bully. And it is one thing if our policies are to protect
ourselves. In other words, I would argue that some of our
efforts toward freedom around the world and efforts related to
the terrorism groups, many in your country or working with law
enforcement or if heroin comes from an area and goes to another
area, it's narcoterrorism, yet we have things we have to work
with together. But if we are not sensitive to each other's
cultures as we do this and if we come ramming in on things that
are largely domestic, we have a problem, particularly if we are
using taxpayer dollars that the majority of the taxpayers and
the majority party in the House and the Senate and the
Presidency don't agree with.
Your testimony, though it seemed short, anything you want
to send to us is very helpful in clarifying it from an
international perspective. Now, at the same time that--and this
is where those of us--I'm a fundamentalist Christian in the
United States, and I have certain policies. There are public
health concerns we have to figure out. And we have to figure
out how we deal with this when these two things hit. And I'm
not arguing because I don't favor harm reduction programs, but
it may not be enough just to say no. We have to figure out not
how to get them involved in drugs, but more creative ways to do
that, how to treat the holistic problem that's behind it, how
to get people who have treatment programs with it and figure
out within our religious faiths a more complicated and
comprehensive approach than ``Just Say No'' as a response, or
we are going to get these what seem like a short-term solution
but often wind up in the long term undermining our
antinarcotics efforts.
Thank you very much.
Mr. Cummings. I have one statement based on what you just
said, and I want to be fair to this side and take a little bit
of time like you have taken quite a bit of time. Let me be real
clear that I think we all agree that appropriate treatment,
treatment works.
Mr. How, you said it. You don't have enough treatment. I
bet almost everybody on this panel will say there is not enough
treatment. So it would be nice, since we are talking about what
we agree and disagree on, that we can agree that treatment does
work. And in a perfect world, as I said before, we had that
treatment, and we spent our money on treatment. I don't think
this country--I hope--wants to bully anybody into anything. But
one thing we do know, that I'm sure the various countries that
you all come from, there are people no matter what their
religion may be that would love to have treatment. And maybe we
need to redirect some of our efforts into trying to have that
treatment so you don't have to go through these hurdles or over
these hurdles when you are trying to get people well. Thank
you, Mr. Chairman.
Mr. Souder. And not a dime of those treatment dollars
should be used for needles. It should go for treatment. Thank
you very much.
The next panel, if you could come forward. Remain standing,
and we will do the oath at the same time.
[Witnesses sworn.]
Mr. Souder. Let the record show that each of the witnesses
responded in the affirmative.
Thank you for your patience. It has been a long, drawn-out
afternoon, and let's go to panel two.
Our first witness is Mr. Robert Peterson from PRIDE
International, a youth organization.
STATEMENTS OF ROBERT PETERSON, PRIDE INTERNATIONAL YOUTH
ORGANIZATION; REV. EDWIN SANDERS, METROPOLITAN
INTERDENOMINATIONAL CHURCH, MEMBER, PRESIDENT'S ADVISORY
COMMISSION ON HIV/AIDS; PETER L. BEILENSON, M.D., COMMISSIONER,
BALTIMORE CITY DEPARTMENT OF HEALTH; ERIC A. VOTH, M.D., FACP,
CHAIRMAN, THE INSTITUTE ON GLOBAL DRUG POLICY; AND ANDREA
BARTHWELL, M.D., FORMER DEPUTY DIRECTOR, OFFICE OF NATIONAL
DRUG CONTROL POLICY
STATEMENT OF ROBERT E. PETERSON
Mr. Peterson. Thank you.
You can reduce the harm to me and probably some of my
teammates by paying our parking tickets when we leave today.
I have been involved in many different angles; was in
charge of funding the treatment, the prevention and the
enforcement in the State of Michigan. More recently, I have
been working with youth in our Nation and abroad and especially
in South America. And as I mentioned in the testimony, the
whole question, is there such a thing as safe drug abuse, it
underlies confusion and mixed messages.
And some of the confusion that's come up here today,
because what we are dealing with, and somebody brought out, is
this whole terminology bit and what are we talking about when
we use these terms.
A lady from Peru, wonderful woman who works with the street
children, she said she showed up at a conference that was
dealing with some of these same issues, harm reduction and drug
legalization. And the young children in the program said, ``Do
you mean there are people that want to make drugs legal and
available out there?'' And the little child said, ``And the
world really has gone crazy, hasn't it?''
And the truth is, maybe these questions don't come up here
about safe drug use, but I can assure you, in Canada, the crack
addicts are pushing for safe crack use kits. So those terms are
being used, and they are being used by groups that are
advocating certain things right here. Each of us looks at the
drug problem a little bit.
If you are a treatment provider dealing with addicts on the
street, you're going to look at the drug problem one way. If
you are a cop on a beat, you are going to look at the drug
problem another way. If you are the head of a church or
counselor, you look at it another way.
My bias now, my life basically--I have been able to get out
of government. I have six children. I have with me here some of
my girls basketball team and some of the boys basketball. And
the key is, you mentioned the criteria should be what the drug
policy impact will be upon youth and families, how is this
going to impact youth and families?
If we look at the drug problem, you can see from children's
view, it is not the drug laws or policy, it is drug use that
causes their problems. Some child in the womb can be damaged by
drugs, can be born addicted. In Philadelphia, during the crack
epidemic, I was with the attorney general in Pennsylvania. It
was estimated 80 percent of child abuse and half of the deaths
were caused by a drug-using parent. It was the use of drugs and
the impact upon the brain of the parents that--the parents
probably otherwise loved their children--caused the problems.
And for younger children, it is the same thing, neglect.
For teens, the top cause of death for teenagers in this country
is accidents, and that relates back to drug use. For young
adults, drug use. You are dealing with date rape, violence,
other types of things. Why this is important will come to bear
in a little bit.
Now, did those working with children and youth develop a
harm reduction concept? Harm reduction as you heard from some
of the doctors is an old concept, and we do use it, but it was
hijacked, OK? I'm a student of the drug culture and listened to
their audiotapes for years of their conferences, and there was
a group in the 1980's funded by some American businessmen that
got together, and they held whole sessions saying what can we
use instead of the L word. What can we use instead of the word
legalization that we sell to the public? And the basic
conception that they came up with was harm reduction.
Peter McDermott wrote, ``as a member of the Liverpool cabal
who hijacked the term harm reduction and used it aggressively
to advocate change during the 1980's, I'm able to say what we
meant when we used the term--Harm reduction implied a break
with the old unworkable dogmas--the philosophy that placed a
premium on seeking to obtain abstinence.''
And he goes on to discuss the need for a legal supply of
clean drugs and a supply, not an exchange, of clean needles.
What we see is a focus to a civil libertarian, a focus to some
of the groups that are funding, whether unknowingly or
knowingly or whether the groups are buying into their
philosophy, whether the board members are buying into their
philosophy, but the groups that primarily fund the major
lobbyists for this concept are involved with a viewpoint that
drugs should be a Constitutional right, that we have an
inherent right to use drugs.
And if you listen to their tapes and listen to the leaders
and read some of their papers, they make this very clear. This
is not a secret. There is a proverb that where a man's treasure
is, there is where his heart lies. Now one of the problems I
have with some of these things with George Soros, and these
people supposedly show so much compassion is they fund very
little of the treatment we are talking about. Money is going
into needle exchange. Money is going into political campaigns
to liberalize drug laws. Very little is going into, of their
money, to actually provide treatment on demand for the addicts.
There is a lot of money there that could be going into that,
and it is being wasted.
One of the things we talk about when we talked about
needles, I believe what we heard and you can straighten me up--
and I know, Congressman, you spoke to the groups and
coalitions, so I know where your heart is with this to make a
difference. But what we heard everybody says, you give needles
with treatment, with outreach, with getting people help. And so
some of the studies that need to be done--we also know that
just giving help and treatment works without the needles. How
much is it the needles, and how much is it the treatment and
outreach?
There are a lot of programs out there throwing needles out
and providing none of these things. Needles are littering the
streets. The return rate is not always 100 percent. So you have
to differentiate. Is this buying the philosophy of moving away
from abstinence, or is it supporting the policy of abstinence?
You are saying using needles to get these people, to get them
in treatment, to get them help, to get them off drugs. It can
be used in the opposite way, that we are going to allow drug
use and going to accept it because some of the same groups that
are funding here and funding in Europe and the main lobbyists
behind this are pushing for heroin maintenance, maintaining
people on heroin, and legalization or liberalization of many of
the drug laws. This is a public record, and you can read their
things. Many of the people who are saying that they support
some form of harm reduction----
Mr. Souder. Mr. Peterson, we will put your whole statement
in the record, but you need to summarize.
Mr. Peterson. The concept has been bought in, but sometimes
people don't know which one they are taking. But the basic
philosophy that is being pushed as harm reduction is this
philosophy of acceptance and accommodation of drug use. I heard
people say again and again, ``We can't solve this problem, so
we are going to have to accommodate and learn to live with
it.'' And I say, ``We can't solve, we haven't solved racism.''
We haven't solved pollution or a lot of other problems that
lasted a lot longer, but we don't give up on them or throw in
the towel.
There is ample evidence that treatment, outreach and
especially drug prevention can be effective. The major threat
to youth of harm reduction, because coming from youth
perspective is that this whole ball of wax, this philosophy
advocates teaching kids responsible drug use, because if they
are going to use drugs anyway, you teach them how to do it
responsibly.
There was a book in the 1970's called, ``Responsible Drug
Use.'' And what it taught was to clean out the seeds in your
pot, to smoke with a friend, to use a roach clip and don't burn
yourself. Guess what? We had the highest levels of drug abuse
among our youth than any civilization has had in the world back
then. That type of teaching and that type of philosophy
resulted in 1 in 10 of every high school senior stoned on pot
every single day of the week. So we know that doesn't work.
Countries have tried heroin maintenance. They have tried--
Britain and the Dutch have done experiments, and it didn't
work. And they are going back to it. So I go back to the
children, and I go back to the child in Peru and say, yeah, the
world has gone crazy, because these drugs are a form of
slavery. And we talked about it with some of the churches. And
the Vatican issued a statement on drug injectionsites and on
some of these very concepts. And what it said is that drug
dependence is against life itself. You are taking life away
from people. It is not just the physical harms or just the
crime and the outside things; it is what it does to the human
spirit, because what differentiates us from all the animals is
that we have a free will and we have human reason. Drugs strip
that away. To say there is a safe way to do that, to strip away
the very dignity of a human being, is to take away their free
will and freedom.
Any form of harm reduction which says we have to accept
some form of drug use, we have to provide drugs, and we have to
make drugs more widely available, I believe is disastrous. I
talk to youth around the globe, and when they hear some of
these things, they are like, how can anybody think that? How
can that be humane? It is being promoted, and it's being
promoted by the very people who are funding and overseeing a
lot of this effort. And they are using some of the things,
narrow things, medical marijuana, needles, but they believe
it's all part of a much bigger package, even if some of the
people involved don't see that.
You can't belong to the board, Drug Policy Alliance, and
all the people that support all kinds of things. Some think
treatment is nonsense and say, I don't know any of these
people. It is ridiculous, and it is a mixed message. And young
people just see the message. They see the mixed message. Thank
you.
[The prepared statement of Mr. Peterson follows:]
Mr. Souder. Thank you for your testimony. Our next witness
is Reverend Edwin Sanders, Metropolitan Interdenominational
Church and member of the President's Advisory Commission on
HIV-AIDS.
Thank you for your patience today.
STATEMENT OF REV. EDWIN SANDERS
Rev. Sanders. I appreciate the opportunity to be able to
testify today. Let me do one thing before I begin, and that is
to make a more clear and accurate response of who I am. I'm
Reverend Edwin Sanders II. I'm the senior servant at
Metropolitan Interdenominational Church. To have my reference
to being a member of the President's council is really a
misnomer and should not be there. I don't represent the
President's council. It is a very vast and complex group of
people, 30-some of us, who represent many different diverse
perspectives with regard to issues. And I do not speak for the
council nor could any of us individually.
I am, though, the director of an organization called
Religious Leaders for a More Just and Compassionate Drug
Policy. And that would be a more accurate way to identify my
relationship to this. And I thank you. I am especially
concerned about the conversation, and it is not important for
me to say what I had in my notes. It is clear that much of what
I would have said has already been said. But let me say two or
three things that I think are very important.
One is, I want to say at least two things about the way we
have categorized and framed the debate. I hope we do not spend
a lot of time dealing with demonization of people who happen to
have alternative positions, and I will tell you why I'm
especially sensitive to that. I spend a lot of my time dealing
with demonization because I'm a member of the Republican Party
and I am a black man. And it is amazing the way which people
come to me and talk to me about the Republican Party being a
hiding place for white supremacists and talking about the ways
in which it ends up being anti-the people that I am most
directly connected to. I think that is a misrepresentation.
That is the kind of demonization that hurts what I stand for
and represent.
The same thing is true in terms of the Drug Policy
Alliance. I don't think I identify with everything that ends up
being a part of all the individuals that are part of that body,
but I know what it's like to be in a situation when someone
holds up a book like the one that was held up a while ago,
which I hope--and I don't know the content of it completely
myself--which I hope is a piece that deals with accurate
information sharing with regard to what marijuana is. I hope
that's what it is.
But it occurs to me what happens around sex education. I
could see a sex education book that has the title to it, it is
a God-given gift and has to be understood in that way. Well, I
think no one is talking about promoting early debut, premature
debut to sex. And I'm sure that there is no one that I'm aware
of on the Drug Policy Alliance who is advocating drug and
marijuana use with children. I would be appalled by that. I
would have spoken out aggressively against it.
And then the whole question of criminalization,
decriminalization and legalization, I must admit, it is
semantics in terms of how we use the language. I am definitely
not an advocate of legalization. Let me tell you the reason
why, and it sounds like what Representative Norton said in
terms of the whole issue of how criminalization plays into it.
I am an African-American, and I do serve a community that ends
up being disproportionately impacted by this horror. And one of
the things I have come to realize is that the criminalization
of drugs has translated into an even expanded horror. You look
at the fact we are 10 percent of the population, and we end up
representing 37 percent of the persons who are arrested for
drugs. And let me note the fact that, in terms of drug use,
most analysis shows it is really white Americans that use
somewhere between 70-plus percent of all the drugs in this
country, but we end up representing 37 percent of those who are
arrested. We end up representing 46 percent of those who are
prosecuted. We end up representing 59 percent of those who are
convicted and 64 percent of those who go to prison.
Criminalization is a horror in our community because of
some of the historical horrors that we still struggle with in
this country. I am not advocating for legalization, but I'm
advocating for a system that creates the avenue to treatment
for all on an equal basis, and that does not happen. So I want
that to be understood.
Let me tell you about Metropolitan Church to some degree
and, more than the church, just my experience. It was around
1990 that I had my first experience dealing with this whole
issue of harm reduction. It was a situation where I was in a
public housing project on a Saturday afternoon, part of a group
called Minority AIDS Outreach, doing a demonstration of how to
clean a needle with bleach, which was the way things were done
in those days. Why was I doing that? A cameraman came up and
threw a camera in my face and said, Reverend, how could you, a
man of God--and I am from Nashville, TN. I don't just live in
the Bible Belt; I live in the buckle of the Bible Belt. And I
fully understand and appreciate what it means to be an
evangelical fundamentalist Christian. And those are people I
relate to everyday in terms of the work that I do.
The guy who threw a camera in my face said, how can a man
of God be here doing this and showing people how to clean their
needles? And I guess my response was the same I have to this
day. My business has something to offer to people who are
alive. In the early 1990's, there were no triple combination
therapies. There were no anti-viral drugs. People were dying.
It was a short one at that point. And I was concerned with the
fact that the disease was shifting; people were still thinking
about the disease as being primarily gay white men. I was
seeing everyday that, in our community, the disease was
starting to spread. And it had to do with a lot of injection
drug use. And I started believing in this whole idea of clean
syringes, just on the basis of how I keep alive--because I'm
trying to offer them salvation and a relationship to a God who
is redemptive, loving. That's the only reason why I'm involved
in it. And I appreciate the science that supports it. But that
is the reason why, because I need live people to offer what I
have in the work that I do.
I see the time is up, and I will try to wind this up and
say it is important to me for you to understand that every one
of our objectives is built around what we call a bridge to
treatment. We don't do anything, whether methadone maintenance
or anything else, that is not ultimately working with people to
bring them to treatment. When Dr. Newman talked about the 80
percent of people who are injection drug users that don't have
access to treatment, what that is, is a result of people who
really are under the radar screen.
I tell people all the time, we reach out doing work with
people who don't have zip codes, Social Security numbers, phone
numbers, correct addresses and, most often, lie about what
their name is because they are under the radar screen. They
are, in many instances, being out of the loop in terms of folks
in society in a way that either allows them to access the
avenues to treatment that we have available. We use a bridge as
treatment. We establish credibility and establish rapport, and
we have a tremendous track record in terms of being able to get
people into treatment and off of drugs. I would be glad to go
further with questions, but I know I probably used up my time.
Thank you.
Mr. Souder. Thank you. And let me point that everybody's
full statement will be in the record, and you heard me say
multiple times, if you have additional comments you want to
insert--and let me say for the record, the Republicans are just
like the Democrats, we fight harder internally than we do each
other. And both parties are pretty much the same.
Rev. Sanders. I get stigmatized all the time for being a
Republican.
Mr. Souder. I should always say that I am sure, when I say
the different titles, that the individual may or may not be
speaking for the whole department, and I appreciate your
clarification, and I should have been saying it all day.
Dr. Beilenson, you are commissioner for the Baltimore City
Department of Health. You have testified numerous times before
this committee.
STATEMENT OF PETER BEILENSON, M.D., M.P.H.
Dr. Beilenson. Thank you, Mr. Chairman, Mr. Cummings and
Ms. Norton.
I, too, am a father of several children, and I, too, coach
girls basketball, but I believe in needle exchange and not in a
vacuum. I think everyone here who has been speaking for the
minority side, if you will, has been talking about needle
exchange as part of a comprehensive drug and HIV/AIDS reduction
policy. That includes prevention, primary prevention and
secondary prevention and includes the ``Just Say No'' issues.
It includes drug treatment.
We have actually tripled treatment, as Congressman Cummings
is well aware, in Baltimore City. So we have gone from treating
11,000 people from 5 years ago to 25,000 people last year, but
we are still not a treatment-on-request or demand. But it also
includes needle exchange programs. And for the last 10 years,
we have run a needle exchange program in Baltimore City,
legally, thanks in part to Congressman Cummings, who was a
delegate who carried this bill in the State legislature and
State General Assembly, and to the folks who have been running
this program with me for the last 10 years who are here.
Let me tell you a little bit about how it works on the
ground and why we so strongly believe in needle exchange. We
have two large vans that go around to 12 different sites, many
of them daily. I have been out probably 150 times to talk to
addicts. And in fact, Congressman Cummings and Delegate Norton
are absolutely correct; this is, unlike, with all due respect
with what Mr. Peterson said, this is the way many hardcore
addicts actually get to interface with the health field. We are
attracting, on average, people who inject drugs 30 days a
month. These are daily users. These are the hardest-core users.
And they don't go to other care, and they don't go directly to
drug treatment. So we run this needle exchange program.
Tied to our needle exchange program, which, again, is a
needle exchange not a needle handout--we exchange dirty needles
for clean ones, so we are cleaning up the neighborhoods
surrounding our needle exchange sites. And everything I'm
saying is backed up by Johns Hopkins peer-reviewed studies,
which we can submit to the record, that have been talked about
in the media for several years. These are not just anecdotes;
these are actual peer-reviewed studies in major journals.
Our needle exchange has been tied from the beginning to
drug treatment. We have about 400 treatment slots reserved for
our needle exchange clients, and we have gotten 2,300
individuals, who would have never gone into treatment
otherwise, into these slots over the last several years, and
they are succeeding in treatment at as good of rates as people
who are less hardcore addicts.
The reason we did this in Baltimore, as Congressman
Cummings and Ms. Norton are obviously well aware, is that
Baltimore has a significant drug problem, not the biggest. We
constantly are touted as having the biggest, but we don't. But
we have a significant drug problem. And when the needle
exchange started back in 1994, 60 percent of our HIV/AIDS cases
were injection drug users themselves. An additional 20 percent
or so were actually partners of those IDUs and their babies.
But 60 percent were drug users themselves. And it was the
leading cause of death--black and white, male and female--in 25
to 44-year-olds in Baltimore and, I would assume, in
Washington, DC, as well. That is why we instituted this needle
exchange program tied to drug treatment.
I came to testify before the 104th Congress, and the
chairman of the subcommittee at that time was Representative
Hastert. And when I talked about Baltimore City's needle
exchange--this is paraphrasing him. I'm not quoting him
directly, because I can't remember from 9 years ago, whatever
it was, he said: If all programs are run like Baltimore's, I
wouldn't have such a big problem, except that it sends a bad
message to kids.
On the way back to Baltimore, I called our friends at Johns
Hopkins, and we instituted a study of high school students in
Baltimore City to look at exactly that issue. And a peer-
reviewed study came out that this needle exchange is not--is
not--associated with increased drug use. It does not give kids
permission. They do not view it as a good thing. They viewed it
as basically a neutral thing or a negative thing about drug
use.
So science, as Congressman Cummings has talked about, has
been really what has been pushed aside here for ideology. Let
me give you three other issues about needle exchange that we
can disprove. Again, remember 60 percent of our cases were
injection drug users in 1994. Last year, we are down to 41
percent of all of our cases in Baltimore are injection drug
users. This does reduce new infections among IV drug users. And
I'm reporting on these three things specifically because Dr.
Voth in his statement talks about three things that should be
shown by needle exchange that, in fact, they do: One, it does
reduce new cases of injection. Two, it actually decreases the
number of drug users. We are down by about 5,000 to 8,000 drug
users in Baltimore City by most estimates in the last 10 years.
And three, it does eliminate dirty needles from around the
areas. It does not make for dirtier areas or more dangerous
areas around needle exchange sites, which actually is common
sense, because it is a one-for-one exchange. And people will
pick up dirty needles on the way to needle exchange, which
cleans up an area around needle exchange sites.
Finally, it is actually not only--harm reduction is not
only important in preventing humane concerns, like people
getting HIV and passing it on to their partners or their
babies, but it saves taxpayer dollars. We used this argument in
Annapolis to point out that the average HIV case costs about
$100,000 a lifetime. It is probably more than that now with the
medications. And if we could prevent just eight cases in any
given year--eight cases of HIV--because our entire cost
including the drug treatment is $800,000, we would save
taxpayer dollars. We have saved hundreds of times that, in the
tens of millions of dollars.
So I would argue that you have to look at science as well
as humanity and that needle exchange as part of a comprehensive
drug policy and HIV reduction policy does make good sense and
can be done in a very safe manner.
[The prepared statement of Dr. Beilensen follows:]
Mr. Souder. Thank you.
Our next witness is Dr. Eric Voth, who is chairman of the
Institute on Global Drug Policy.
Thank you for coming.
STATEMENT OF ERIC A. VOTH, M.D., FACP
Dr. Voth. Thank you, Mr. Chairman. First, by the way it is
Voth.
I have spent well over 25 years involved in this issue, and
I have been involved in chemical dependency for 10. I spent
enormous amounts of time tracking the drug culture, and I would
echo Bob Peterson's comments that harm reduction has been
hijacked by the decriminalization movement. I quote Pat O'Hare,
who is the director of the International Harm Reduction Society
who said, ``If kids can't have fun with drugs when they are
young, when can they.'' And I would also point a finger
directly at the Drug Policy Alliance, Marijuana Policy Project,
the Open Society Institute, all funded by George Soros. Keep in
mind that we are mixing issues definitionally here, and the
only issue is not drug needle exchange. It is a much broader
issue, and the treatment is harm elimination. What we want is
harm prevention and harm elimination and that harm reduction
can be giving up on the addicts. And I want to talk about
specific examples.
We talked about needle exchanges. There are prevention
programs around the country that talk about responsible drug
use. There are handout programs that are being looked at in
Vancouver and British Columbia. And also, we have talked about
Switzerland. They are looking at safe injection rooms in
certain areas, responsible crack, cocaine-use kits,
decriminalization schemes and medical-excuse marijuana. Let's
talk about needle exchange for a moment.
First of all, there should be three measures as to whether
needle exchange works. First, is there a consistent reduction,
consistent reduction in Hepatitis B, C and HIV? Is there, No.
2, a significant actual reduction in IV drug use by virtue of
people coming to treatment, going to treatment and getting
clean? And three, is there elimination of dirty needles on the
street?
When the CDC looked at this in 2001, of all the North
American needle exchange programs found that 38 percent of the
needles were not returned, which totaled 7 million needles,
among the ones that were looked at just in that year alone, and
realized the requirements for needle exchange are 4 to 12
needles per day, per addict. It is impossible to keep up with
the entire requirement to keep addicts in clean needles.
Second, we have not talked about the well-put-together
studies that actually looked at the Montreal needle exchange
program and found that HIV conversion was twice as high among
the needle exchange participants as in non-participants. The
Seattle needle exchange looked at Hepatitis C, where it was
more significant; the India needle exchange programs where
Hepatitis B, C and HIV have gone through the roof; or Puerto
Rico, where at low, only 12 percent of the needles were turned
back in. That constitutes needle handouts. Only 9 percent, by
the way, in that Puerto Rico needle exchange actually sought
treatment. Needle exchange doesn't fundamentally do anything
for the underlying addiction.
I want to jump to this issue of responsible drug use. You
have seen this book called, ``It's Just a Plant.'' That book
does go on to say a little girl quoted--and this is directed at
preteens--``I want to go home and grow my own marijuana
plant.'' It's financed by the Drug Policy Alliance, Marijuana
Policy Project, thanks to George Soros goes in the forward in
that book.
The medical-excuse marijuana movement is a perfect example
of how Soros and friends have undermined the FDA. They have
created medicine by popular vote rather than science. This is
in your pamphlets. I highly recommend you read it. It documents
Soros' money funding the whole marijuana legalization movement
as it relates to medical-excuse marijuana.
Some examples of failed harm reduction, the 10,000-foot
view. Let's look at Vancouver; 27 percent of the needle
exchange folks there share needles, and 50 percent of those who
use methadone and are in the needle exchange program share
needles. They are spending $3 million a year on safe
injectionsites, but still have 107 overdoses. Their overdose
rate is their leading cause of death of people aged 30 to 49,
and now they are going to add to that with heroin handouts.
With all due respect, in Baltimore, the violent crime rate
in Baltimore exceeds New York, San Diego, Dallas, San
Francisco, Denver, L.A., Miami and Atlanta, and the overdose
deaths there are at least twice that of Chicago, Dallas,
Denver, New York and a third higher than Philadelphia. I am
glad to see they believe they have had some forward motion
there.
We can talk about Switzerland and Holland. The big picture
with harm reduction policy is, who are going to be the winners
and who are going to be the losers? The people that profit from
the sale and distribution of drugs will win. Those who want to
continue using will win. And those who hope to profit from the
futures investment market will win. And the losers are clear:
kids, families and drug abusers themselves. And I would hope
that you would stay away from harm reduction policy and
embrace--reap harm elimination and harm prevention policies.
Thank you.
[The prepared statement of Dr. Voth follows:]
Mr. Souder. Thank you very much. And our clean-up hitter
for the day is Dr. Andrea Barthwell, who was our long-time
Deputy Director of the Office of National Drug Control Policy
[ONDCP].
Thank you for coming back again before our subcommittee.
STATEMENT OF ANDREA BARTHWELL, M.D.
Dr. Barthwell. Thank you, Mr. Chairman.
Mr. Souder. I think you need to hit your----
Dr. Barthwell. Is it on now?
Mr. Souder. Maybe you just need to keep it closer.
Dr. Barthwell. Thank you, Mr. Chairman, for having me. Mr.
Cummings, it's good to see you again, thank you for this
opportunity to testify.
Nonmedical use is a preventable behavior. Nonmedical drug
use is a preventable behavior, and an addiction is a treatable
but fundamental disease of the brain. Years of research with
both animals and humans teach that drugs of abuse have
profound, immediate and long-term effects on the chemical
balance in the brain.
Drug use can be described along a continuum of three
groups, non-users, non-dependent users and those with abuse or
dependence.
Non-users have never used, those who are not using and
those who intend never to use, sometimes as being described in
recovery. A key public policy goal is to keep non-users from
using. The environment that supports non-using norms also
supports recovery. The non-dependent user sits at the
crossroads of non-users and dependent users able to return to a
non-using state with the right incentives, yet apt to progress
to a more chronic severe debilitating form of use with the
wrong incentives.
When individuals use a drug of abuse for the first time,
they either stop when the drug fails to deliver all that was
promised or when external controls are applied, or they
continue to use. New users' novel pleasurable experiences
combined with their desire to normalize their own behavior lead
them to recruit other new users.
Nondependent users fuel specific drug epidemics in the
United States from cocaine to heroin to methamphetamine to
Oxycontin. Public responses focus on the drug itself. Policies
have failed to focus on the real source of the epidemic, the
pool of non-dependent users who exist in communities across the
country virtually unaffected by current drug policy.
Regular use of drugs in sufficient amounts can lead to a
state in which the user comes to prefer the drug condition and
in which the brain chemistry is so disturbed that the user's
voluntary control of his or her behavior is impaired. These
hallmarks of addiction make it difficult for dependent users to
stop using. The cost of dependent use on the users themselves,
their families and society as a whole are profound.
In order to break the cycle of chronic drug use, drug-
dependent individuals must undergo significant changes in their
lifestyles and attitudes. They usually need help doing so.
Behavioral, medical and psychological treatments are the
cornerstones of services available to help dependent users
achieve and sustain meaningful periods of abstinence.
Our Nation's drug policies must be broadly designed to meet
three goals. Stop the initiation of drug use, change the risk-
benefit analysis of non-dependent users and provide brief and
early prevention to those who abuse drugs and treatment to
those who are dependent on drugs.
It's in our best interest to embrace scientifically sound
policies to reject in an informed way those policies and
practices that don't help us achieve our broad and national
goals. No matter how attached to them we are, no matter how
much we like them, we must fully grasp that policies that
address thorny issues cannot be allowed to prevail if they
create unintended consequences in other areas and impede our
achievement of our national goals.
A perennial question among policymakers as it is today is
whether harm reduction strategies make effective drug policies.
The term harm reduction in drug policy refers to practices that
promote safer ways to use drugs in which the primary goal is to
enable drug users themselves to direct the course of their own
sanctioned drug use, not to stop their drug use.
At first glance, there may appear to be numerous societal
analogs at policies aimed to reduce the harmful consequences of
non-medical drug use rather than eliminating the use itself.
Safety implements such as guardrails and seat belts reduce
inherent dangers of automobile travel, but placement of
lifeguards on public beaches reduce the likelihood of drowning.
They seek not to prohibit potentially dangerous activities but
to alter the conditions under which these activities occur.
There is, however, a logical flaw in equating harm
reduction measures for activities mentioned above with harm
reduction strategies for drug use. Despite their risk, these
activities involve common, socially acceptable behavior. Given
that it would be neither desirable nor realistic to attempt to
prohibit these activities, harm reduction is the only viable
option.
You heard earlier clinically trained physicians such as
myself worked to achieve harm reduction within visible chronic
diseases, true. These chronic diseases can only be controlled,
not cured.
This chronic progressive disease addiction, however, cannot
be controlled, but it can be cured, and untold numbers of
people in recovery are testament to that.
The non-medical use of drugs, on the other hand, does not
constitute common or socially acceptable behavior. Preventing
and eliminating non-medical drug use is both desirable and
realistic. Sanctioning drug use has not produced desirable
outcomes.
Harm reduction is a part of society's approach to harmful
tobacco products, because legally available, yet they must be
managed. These efforts are based upon an assumption that use
occurs, and we must as a society manage it.
Contrasting tobacco products against crack cocaine
illustrates that, when possible, prohibitions on use are
preferable.
Some 40 years after the harms of tobacco consumption became
commonly known in the United States, 35 million hardcore
nicotine addicts appear unable to quit. Nicotine provides an
example of what can happen when a rewarding addictive drug is
readily available. Like nicotine, crack is easily administered,
smoked. Animal self-administration experiments suggest that
cocaine is greatly preferred to and more addictive than,
nicotine.
Unlike tobacco, however, crack cocaine is prohibited. As a
result, the number of Americans who use crack cocaine weekly is
less than 1 million. Easy availability, stemming from lax legal
controls, has permitted far more people, often adolescents, to
become addicted to nicotine than the more pleasurable and
addictive cocaine.
To avoid harm, not just to reduce it, these pleasurable yet
addictive substances that are currently prohibited from us must
remain prohibited.
Harm reduction efforts are inconsistent with three broad
goals of drug policy. Then I will close.
First, harm reduction strategies cause harm to non-users.
The best way to reduce harm to non-users is to keep them off
drugs. The best way to keep them off drugs sincerely is to
foster a non-using norm. Harm reduction policies undermine the
non-using norm by creating ambiguity as to the illegality,
dangers and social consequences of drug use.
Harm avoidance is the goal. Harm reduction does not satisfy
the goals of the grandmother who wants to keep kids off drugs.
Second, harm reduction strategies cause harm to non-
dependent users with pleasurable drug-using experiences and
few, if any, consequences; the internal incentives for the non-
dependent user to stop using are few. External influences are
imperative to preventing the non-dependent user from
progressing to abuse or dependence. Harm reduction strategies
undermine the non-using norm and reduce the external deterrents
to drug use by perpetuating the notion that drug use can be
controlled.
Taking it one step further, harm reduction campaigns
provide the actual tool for drug use. Harm reduction serves the
purposes of the non-dependent user.
Finally, harm reduction strategies cause harm to
individuals suffering from abuse and dependence. Quite simply,
treatment research recognizes that dependent users have lost
voluntary control over their drug abuse. Whether they want to
stop using makes no difference. Stopping outright is necessary
to treat the disease and ensure the patient's survival.
I want you to explain harm reduction to the six children
who lost their mother to AIDS, contracted from unprotected
intercourse to get money for heroin shot through a clean
needle. Harm reduction is harm promotion in the end, and we
have to ask ourselves what is the sense in that.
[The prepared statement of Dr. Barthwell follows:]
Mr. Souder. I thank you all for your testimony.
Let me ask a couple questions about Baltimore, Dr.
Beilenson. Did you say that the total heroin drug use is down
in Baltimore?
Dr. Beilenson. The estimate is that we have gone from about
50,000 to 55,000 to 40,000 or so folks. It's not a very good
survey, but it's the best estimate.
Mr. Souder. One of the difficult things in estimates, and I
remember when I was a staffer, there was a study done on birth
control clinics at high schools in Minneapolis, and they showed
that there had been a reduction in teen pregnancy. The problem
was that in the schools where they didn't have the clinics, the
drug use went down even more. I mean, excuse me, teen pregnancy
went down even more. The national average in the United States
has declined faster than your average.
Dr. Beilenson. Well, that may be. Needle exchange only
serves 13,000 people. We have more than that, obviously, that
use drugs, so it doesn't totally relate to it.
But as a support, the DAWN data was being used in, I guess,
in Dr. Voth's statement, written statement. We have shown the
second largest drop in drug-related emergency room visits in
any of the 21 major urban areas, second, I think, only to
Dallas over the last several years. So we are, in fact, seeing
a decrease in drug use and the consequences of drug use.
Mr. Souder. Or at least you are maintaining them on heroin
so they are not----
Dr. Beilenson. No, no, we are not--well, needle exchange is
not heroin maintenance.
Mr. Souder. Why would they need a new needle?
Dr. Beilenson. I'm sorry, what?
Mr. Souder. Why would you need a clean needle if it is not
maintenance?
Dr. Beilenson. Oh, because we are not providing the heroin.
Clearly, they are using drugs, and they matched the point of
harm reduction. If you are not going to get clean, at this
given time, that doesn't mean that you later will not. We
have--I think you have dozens of people out there who have
gotten clean or have been prevented from getting HIV from dirty
needles.
Mr. Souder. Would you agree that the problem is, if you
haven't had a greater reduction than the rest of the United
States and if your crime rate and the population of Baltimore
has declined and if you haven't had--I mean, if you haven't had
clear changes in crimes--emergency room visits are an estimate
of gain of the severity of the drug addiction, I would grant
that. It's not--so that you aren't drug addicted, but it may
mean because you are getting clean needles you are staying on a
fair level playing field of heroin; you are not overdosing on a
regular maintenance program with it, much like they do in
Switzerland, only, like you say, you don't provide the heroin
like Switzerland.
But, in fact, by having regular supervision, they don't go
to the emergency room. In other words, emergency room visits
are not a criteria of whether you are addicted to heroin.
Emergency room visits are a criteria of whether you have
overdosed.
Dr. Beilenson. No, that is actually, excuse me, I am sorry,
go ahead and finish.
Mr. Souder. Do you think anybody who is using heroin would
go to an emergency room? What was I----
Dr. Beilenson. Oh, oh my. Absolutely.
Mr. Souder. No, no, no. But, would you agree that you can
use heroin and not have to go to the emergency room?
Dr. Beilenson. Yes.
Mr. Souder. My argument was what that means is that you
control a level, arguably, of it; emergency room visits do not
show that you have gotten people off heroin.
Dr. Beilenson. No, that's actually not true. If I may----
Mr. Souder. How is it not correct?
Dr. Beilenson. Being a practicing physician myself and
being on the faculty at Hopkins, in addition to being the city
health commissioner for almost 13 years, I have seen this
personally as well as being an intern, etc., that the way that
the drug related emergency room visit date is collected, DAWN
data, is any mention of drug use in the chart. And most of them
are not overdose. In fact, we are talking thousands, as are
most cities. And hundreds or fewer are actually overdoses.
Most of them are cellulitis due to skin popping, skin
infection due to skin popping, things--heart infections, like
subacute bacterial endocarditis, again doing injection drug
use, hypertension, sometimes secondary to substance abuse.
So any of those mentions show up, and so, in fact, it is a
pretty good marker that there is less drug use going on--and
remember that many, most of our addicts, as Congressman
Cummings is very well aware, do not have health insurance and
in fact use the emergency room as their primary source of
healthcare.
So, in fact, I would argue that the drug-related emergency
room visit decrease does make a difference.
Second, our violent crime rate has dropped in the last 4
years, 41 percent faster than any other major city in the
United States.
Mr. Souder. Well, we are fencing with statistics, but first
off, because you were so high, you can conceivably have a
quicker drop. Your crime rate is still very high. But that's
good news, crime rate is dropping across the country.
Dr. Beilenson. Yes.
Mr. Souder. It is not dramatically different at 41 percent.
If you have a 17 percent--are reductions in emergency rooms
greater than 17? You roughly had in 55,000 to, 44,000,
understanding that was a rough estimate, somewhere between 17
and 20 percent reduction. Did emergency rooms go down by that
percent?
Dr. Beilenson. I honestly can't remember. I just know it is
the second faster drop of the 21 biggest cities.
Mr. Souder. Because all my point is, at most, you can argue
that you could make an argument. I am not making the argument
for you, but you could make an argument that for me to say that
it absolutely doesn't work isn't clear, but you can't make an
argument that in fact it does work if your statistics aren't
dramatically different than other cities in the United States
that don't have the program.
Dr. Beilenson. I think you might be able to say, taking a
step hypothetically, that looking at the local issues in
Baltimore City statistics, you could say, well, maybe it
doesn't work. You can't prove that it is working on the global
level.
We can show by these peer-reviewed Hopkins studies--I mean,
probably the best public health school in the United States,
probably in the world--has shown a 40 percent decrease in new
cases, not in the needles, as some people talk about, but in
the people, because we test our folks frequently, every 6
months, that those enrolled in the needle exchange are
converting to HIV positive 40 percent less frequently than the
other matched addicts in the cities that don't use needle
exchange.
Mr. Souder. What about--are you doing counseling with them,
too, treatment?
Dr. Beilenson. Oh, yes.
Mr. Souder. What about Mr. Peterson's comment, if they were
getting that, you would see that reduction anyway?
Dr. Beilenson. Because as I said before, we are seeing----
Mr. Souder. Wouldn't come in, is that correct?
Dr. Beilenson. That's correct. When we--and actually
there's a study that's been on that as well that have shown
these were hardcore users who have not had treatment before.
Mr. Souder. So, basically, is there treatment on demand in
Baltimore?
Dr. Beilenson. No, we are not there yet. We need to have
about 40,000 slots. We are at 25,000.
Mr. Souder. So basically you are running this program and
giving them this special treatment when others can't get it.
Dr. Beilenson. Wait, I don't understand.
Mr. Souder. In other words, if you can't meet everybody who
needs treatment, and these people are getting it, it goes back
to Mr. Peterson's argument.
Dr. Beilenson. Oh, I see what you are saying.
Mr. Souder. You are not really disproving or proving the
effectiveness of your program. You may be proving the
effectiveness of--who follow and work with individuals.
Dr. Beilenson. No, these are--but, again, these are addicts
that are coming to us.
Mr. Souder. But if you use that same thing on other addicts
who weren't addicted to heroin or were addicted to heroin, who
came to you who weren't this hardest-to-reach population, you
might have a greater dispute. That is hard to prove----
Dr. Beilenson. I understand exactly what you are saying.
But as Congressman Cummings has been pointing out, is our
ultimate goal treatment on demand, absolutely. And we have
tripled funding for that. But I do want to point out--as I
think Rev. Sanders, and I don't want to speak for him, but I
think was pointing out that, since Mesopotamian times, 5,000
years ago, people have been inventing mind-altering substances
and using them; ``Just Say No'' makes good sense. I went to
school with Ronnie Reagan. Governor--President Reagan held the
chains on the sidelines of my 5th grade football team. I know
Nancy Reagan; ``Just Say No'' is great. That's what I say to my
teenage kids.
Mr. Souder. By the way ``Just Say No'' led to the greatest
reductions, 11 straight years.
Dr. Beilenson. And I am not disagreeing, but we still have
millions and millions of people still using. Even if you have
treatment on demand, you will still have people using, and it
makes sense to reduce harm, not just to themselves but to their
partners, to their babies and to taxpayers, to have programs
like this available. I am not saying that abstinence is not the
ultimate goal. I totally agree with that.
Mr. Souder. I find the Baltimore statistics interesting,
which is why I wanted to go into an extended discussion.
Clearly, as Dr. Voth has pointed out, isn't true for
Montreal, isn't true for Vancouver, isn't true for Seattle; in
that Baltimore is an interesting case.
At most, I believe, you are arguing that it hasn't done
additional harm like, in my opinion, some of those programs
have. I know there are disputes on those statistics in other
cities, but they do not even begin to make the argument that
you are making for Baltimore.
Dr. Beilenson. Well, if I can, I mean, you may want to talk
to other people, too. Again, by attracting the hardest-core
users--remember the Hep C number, Hepatitis C number, makes
sense that you have hardcore users have higher rates because,
in fact, 85 to 90 percent of injection drug users that are
chronic drug users in the United States and every state are Hep
C positive. So you would expect, actually, as you have hardcore
users come into your needle exchange, they would have higher
rates of Hep C. What you want to look at is change of new
cases, and that's what we can demonstrate in Baltimore in a
well-run program.
Mr. Souder. Thank you.
Mr. Cummings.
Mr. Cummings. Yes. It may be, it just may be, Mr. Chairman,
that we have an outstanding health commissioner, just maybe,
who is doing a great job. I mean, that does happen in the
United States, and we do live in a city where we have one of
the top health institutions in the world, Johns Hopkins. But
that's just maybe.
Rev. Sanders, I don't have my glasses on, I'm sorry.
Rev. Sanders. That's all right.
Mr. Cummings. Here is a term that I just found so
interesting and makes a lot of sense. You talked about the
bridge to treatment. Could you talk about that a little bit,
the bridge to treatment?
Rev. Sanders. Sure. One of the things that is important for
us. We have discovered that you get people into treatment--who
are out of what I would say is the loop of social involvement
that allows them to be able to pursue traditional routes--by
developing rapport and developing the ability to be able to
encounter them.
What I was trying to make is the point that many of these
folks who end up in the numbers, that do not have access to
treatment, it is really because they are out of the social
patterns that allow them to be able to take advantage of
traditional avenues that are available. They don't show up.
Their lives end up very often being driven by how they get the
next fix and how they continue to perpetuate a lifestyle that
has long been addiction.
By engaging them at that level, we begin to talk about--and
let me just tell you this to begin with--every program--and by
the way, we do not have a needle exchange program anymore in
Nashville. We haven't had it for a number of years, because we
decided that, well, put it like this, there is not a formal
needle exchange program in Nashville, mainly because we realize
that it compromised our ability to take advantage of
comprehensive strategies that were available to us.
And I would argue that we need to keep focusing on this
whole question of a comprehensive drug policy. It's not a
either/or, and I think we need to talk about how you develop
the kinds of protocols, how you develop the kinds of
procedures, how you develop the kinds of structural norms that
would be able to allow us to guarantee that we are using all
that is available to us, would help.
So what we do with our bridge to treatment is we engage
people. Now that happens more through our methadone initiative
that we have, and it helps us to be able to bridge people into
a formal treatment situation, not just people who are getting
dosed on methadone and maintained on methadone--I know people
who have been maintained on methadone for years. Our whole
thing is to get people into and move them toward treatment.
That was the strategy that's been used in terms of the RIMS
exchange. It is the strategy that is being used in terms of
methadone. It's the strategy that we use in terms of reaching
those who are normally unreachable folks.
But every one of our protocols and every one of the
initiatives that I have ever been involved with starts with
abstinence. We start off by saying, don't use. I mean, that's
what you want. I had an interesting question. Somebody asked me
about that a couple of years ago. They said, well you tout the
fact that all of your protocols start off with abstinence. If
you looked at your resources, what percentage of resources go
to abstinence versus what percent go to harm reduction?
And I decided to look at that very closely. And I found out
that it actually ends up being pretty significant, the part
that goes to abstinence. Because what we end up going to in
counseling, what we do with people who manage cases, is always
the emphasis on stop using. But the fact is, we try to make
sure that the avenues are open that allow people to be able to
access treatment in the most effective ways they can.
Mr. Cummings. You know, I think that anybody listening to
us, I don't want anyone to ever get the wrong impression--and I
think Ms. Norton said it best. Nobody here is talking about
legalizing drugs.
And if anybody has seen the pain that a drug addict goes
through and the fact that you are dealing with the ghost of the
person--you are not dealing with them, you are dealing with the
ghost of them--nobody buys that. I don't think any, that I know
of and what I hear about the term reduction in this whole--what
is it, reduction therapy being hijacked, I think--I don't
want--just because you come, Reverend, and you, Dr. Beilenson,
and others have come to talk about this, I just want to make
sure that you all are not of the view that drugs should
necessarily be legalized.
I know I have heard you talk about, Dr. Beilenson, about a
health issue, making it a health issue and whatever. But the
suffering is so great to anybody. And we would all like for
nobody to use drugs. I mean, but the fact is, they do.
The Vancouver study, Dr. Beilenson, are you familiar with
that? Because it seems like that comes up all the time.
Dr. Beilenson. Yes, fairly familiar.
Mr. Cummings. If it--do you see that as a success?
Dr. Beilenson. Yes. Let me give you the analogy. Again,
they are serving higher, harder-core addicts. It's as if you
were--compare it to less hardcore addicts. It's as if you
compared sick people and how sick they were in the hospital
compared to a private doctors office. Well, obviously the
sicker people are in the hospital, and you are going to have
higher rates. In fact, that's exactly what Dr. Strathdee, who
is the lead investigator on the Vancouver study, has said and
has clarified in the comments that you were making earlier
today.
Mr. Cummings. So, as far as Baltimore is concerned, how is
that program different than Vancouver, because it seemed like
the chairman was kind of making a little contrast/comparison
thing going on. I don't know what he was doing.
Dr. Beilenson. To be honest, I am not exactly sure how they
are run. Ours is a legal program. Theirs is legal as well, but
I don't think it's----
Mr. Cummings. What do you attribute Baltimore's success to?
Dr. Beilenson. The fact we keep very close tabs on our
data. We have had excellent people Michelle Brown, Lamont
Cogar, since the very inception of the program. We have very
dedicated staff. We do a lot of outreach, and we have fairly
comprehensive services, which bring people in as the bridge to
treatment, that have made a big difference in people's lives.
Mr. Cummings. I don't have anything else.
Mr. Souder. Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
Dr. Barthwell, I am trying to, particularly in light of
your scientific background, I was interested in your testimony.
I would just like to ask for some clarification. On page--these
pages aren't numbered--you discuss nicotine.
Are you suggesting in your testimony that selling of
cigarettes in the United States should be prohibited
absolutely? I am reading here because of your contrasting with
the fact that we have tolerated nicotine, and then you go on to
make analogy to crack cocaine, as if because we have nicotine,
because people smoke cigarettes, it was easy to move on somehow
to crack cocaine; otherwise, don't know that has been a trend
of those who smoke cigarettes. Some of us wish that everybody
would stop smoking, but I wish you would clarify, under the
heading for public health, prohibition is preferable.
Dr. Barthwell. Right. I am not suggesting that we do
anything about nicotine. I am contrasting our experience with
nicotine with that of cocaine. It is very clear in animal study
models and in human studies that cocaine is a much more
powerfully reinforcing substance than nicotine. Animals will
bar press more to get it, once it has stopped. And you
substitute a placebo instead of the cocaine itself, they will
work harder to try to get it reinstated, when compared to
nicotine.
But if you look at the numbers of individuals in this
society who use tobacco products versus the number of people
who use cocaine, the sizes of the populations are vastly
different. Part of it is because nicotine is readily available,
not prohibited, and cocaine is prohibited.
It is very clear from looking at the data and understanding
human behavior, that people do more of that which is sanctioned
and allowed than that which is prohibited and disallowed. And
you have a different level of control on cocaine than on
tobacco, but you have many, many, many more people using
tobacco than cocaine, even though cocaine is much more
powerfully reinforcing than nicotine.
Ms. Norton. I can only, when I read your testimony, and
even hear your explanation, Dr. Barthwell, I can only think
that you are the greatest enemy to the tobacco industry, and I
welcome you to the club.
Some of the sweeping statements you make really interested
me in talking about--again, we get into this word harm
reduction.
Again, for scientists to make such unqualified sweeping
statements is itself interesting. Dr. Beilenson has testified
about the effect of a carefully done needle change program. The
chairman has tried to indicate, tried to take him on at least
on his scientific methology. Do we know cause and effect? All
of that is fair.
I contrasted how you deal with methadone with how you deal
with something lumped under harm reduction. I remember when
methadone was introduced. There is great abuse of methadone as
well in many communities. Those communities where methadone is
administered, not as carefully as Dr. Beilenson's program,
complain about methadone clinics, yet scientists like you
understand that, despite possible abuses, the benefits of
methadone overwhelm the problems, and you get those methadone
clinics under control rather than say, you don't do methadone
clinics.
Now, analytically, you seem unwilling to transfer that kind
of thinking that you do quite readily by simply defining
yourself out of harm reduction. By telling, by saying, well,
but you know, it's an approved drug, so methadone is not harm
reduction but all of that other stuff, and I am not sure what
you are talking about, because you sweepingly say harm
reduction, you all are on the wrong side; I am on the right
side because I have said I am now defining myself out of harm
reduction. I am going to take you to some communities in the
District of Columbia where they would define you right back in.
Because sometimes methadone is not administered as well as
needle exchange is done in Baltimore.
You say--and let me ask specifically some questions in the
part of your testimony that is sweeping. In talking about how
certain techniques lead people not to internalize the need to
get off of drugs in your testimony--this is under the heading
of harm reduction causes harm, blankedly, harm reduction causes
harm.
That's it. Right up against the wall, all of you all,
everything you are doing. I am not telling you what harm
reduction is. I am just telling you that what I would like is
not harm reduction methadone. All the rest of you are doing
harm. That's just how blankedly it is stated, Dr. Barthwell.
Here is my question, you do say, however, external
influences are imperative to preventing the non-dependent user
from progressing to abuse or dependence. You have heard me and
others question witnesses about legalization, heroin
maintenance, that kind of thing and heard definitively people
who are involved in what I am sure you might call certain harm
reduction approaches believe that legalizing drugs is wrong.
In speaking about external influences, Dr. Barthwell, I
have to ask you, have you ever heard of ``three strikes and you
are out'' mandatory minimums or the sentencing guidelines.
Dr. Barthwell. Uh-huh.
Ms. Norton. Would you not call those particularly strict
external influences on non-users or, as you call them, non-
dependent users, as well as users? Is that what you think,
alone, society should depend upon to--as you say, stopping
outright is necessary to treat the disease and ensure the
patient's survival?
Dr. Barthwell. May I respond now? My testimony is written
in the way that it is. I knew where I was going to be on the
panel. I saw all the people who were going to come before me. I
knew they had very data-laden presentations.
I will provide to you and the other members here the
research upon which I have based my conclusions, and I have
about four pages worth of studies that were reviewed in
preparation for this.
You have a synthesis, my understanding of that, and the
references that I am going to provide to you.
Ms. Norton. Do you have particular harms in mind when you
say under the blanket statement that all of these are harm
reductions? Would you tell me the kinds of harm reduction
techniques you have in mind?
Dr. Barthwell. Yes. I thought you had six categories of
statements that you were making about my testimony. I am trying
to respond to them in turn. If you don't want to hear about why
the statement is written the way it is, I will go on to the
next one.
Ms. Norton. It is not that I don't want--I have the right
to intervene to ask you to clarify what you are saying. I want
to hear each and every part of your answer.
Dr. Barthwell. I will take them in turn. I don't agree with
all the studies that were reviewed. And giving them to you is
not an endorsement of them, but it was critical to me to have
an understanding of the breadth of our understanding of this
issue.
As you so aptly point out, it is the methadone itself that
is not problematic; programs and clinics have been demonized
because of the way in which they provide their services. And a
large part of that is because of inadequate funding for an
increase in the intensity of the needs of patients over time.
Some of it has to do with disparities and funding of
clinical staff in them. They don't have access to higher-paid
counselors as some of the abstinence-based programs. So there
are a number of problems that are associated with the provision
of methadone therapy in this country that has little to do with
the medication itself and more to do with the system of care.
But I like the fact that you know that there's a difference
between how a good methadone program operates and how a poorly
resourced or poorly run----
Ms. Norton. Just like there's a difference between a badly
run needle exchange program and one that's well run.
Dr. Barthwell. Absolutely. I have no argument that a poorly
run needle exchange program will, in fact, probably be
associated with more harm to the community in the same way that
a poorly run methadone program is associated with more harm to
the immediate community.
But I have a lot of concern, having watched good ideas come
along and then be inadequately funded, that to go down this
path, you are not going to get programs that are supported with
the research dollars, the high level of science, the integrity
and fidelity to the model that you are seeing described in the
Baltimore program. And, in fact, if you look at the way most
are run, they are not run to that standard. So we are actually
opening a Pandora's box.
Ms. Norton. I don't know that, and I am not sure you know
that. I am not sure you can point to a study that has looked at
methadone maintenance programs across the country, and you can
conclude that most--that's another sweeping statement--are not
run the way they are run in Baltimore.
You know what, Dr. Barthwell, close them down, because you
and I would be on the same page on that wouldn't we?
Dr. Barthwell. I agree. Part of what I have spent my life
doing in the Chicago area is trying to increase the quality of
care that is delivered in those programs that are there. But I,
you know, I will take you to places, too, as you have offered
to take me to places in the District, where there is not
fidelity to the model or the intent, once it is funded and it
goes out there. I think that is a very serious issue for
consideration, for expanding something that is a novel idea,
that is highly researched and highly resourced.
I listened to the high school data as the evidence that
needle exchange programs don't influence the perception of drug
use in a positive way for young people. Unfortunately, our
targets for prevention are between 9 and 12. They are not high
school students. And high school students have very well-formed
ideas about drug use by the time they get to high school.
So until we see the data on what it means to the 6 to 7 to
8 to 12-year-old, I am not sure that we can say that we
understand that needle exchanges do or don't move more toward--
sometimes subtle and sometimes not subtle ways--our community
toward a tolerance of drug use.
Ms. Norton. You think 9 to 12-year-olds are into watching
what happens in needle exchange programs?
Dr. Barthwell. I think 9 to 12-year-year-olds look at a
number of things that are communicated to them about drug use
and are affected by the models that the adults in their----
Ms. Norton. Although there is no research to that effect,
you would like to see it done?
Dr. Barthwell. I think that we probably shouldn't see it
done. I don't think that we should be at a point where we are
looking to see what impact the needle exchange is having on an
8-year-old. I don't want to see the proliferation of needle
exchanges.
The other notion is that there are these positive results
being reported from the Baltimore study. I think, before we
accept them wholesale on review of the literature, you have to
look at the amount of money that is being spent per patient and
per encounter, and if it is really of value because needles are
being provided, or is it really of value because there is an
intense outreach effort which is supported by clinical care and
support once the person has been engaged.
I resent dangling needles in front of addicts to lure them
into treatment. I might believe the proponents of needle
exchange programs were much more genuinely inclined toward
trying to get people off of treatment if they put that same
amount of effort in fighting for programs where needles were
not a part, and they did a side-by-side comparison of all of
the same services with needles and all of the same services
without needles.
Ms. Norton. What about the effect of keeping the injector
from, in fact, infecting innocent people in his or her
community, is that worth a needle?
How are we keeping him from doing that? Because he doesn't
get HIV. Because he turns in his needle every day and gets a
clean needle.
Dr. Barthwell. You know, again, I would like----
Ms. Norton. Doesn't get Hepatitis C, for which there is no
vaccine, HIV/AIDS.
Mr. Souder. Even Dr. Beilenson didn't make that claim.
Dr. Barthwell. I am recommending that we, you know, rather
than resource needle exchange and leave people with a chronic
treatable disease, that we put that resource into giving people
more treatment and that we also move our efforts upstream so
that we don't have as many chronic severe debilitating forms of
dependence that we do in those communities.
And I really want to make the case in these broad sweeping
statements that I am using that to look for a solution and a
narrow slice of all the drug policy and find one, that, you
know, seems to meet most of our needs without anticipating or
studying anticipated unintended consequences across the full
spectrum of drug control, is not advisable at this point.
We have had drug policy that has been based on--focusing on
two sets of populations, non-users for prevention and dependent
users, and we have spent quite a bit of our time and energy
over the last 15 to 20 years and our resource dollars trying to
find more and more discrete ways of treating people with
chronic severe debilitating forms of the disease, you know,
that are very discrete subpopulations of all of the people who
have dependence. What we have done in doing that and in
focusing on drug policy in that way is that we have failed to
treat people who are not those so-called hardcore users, and we
have not addressed non-dependent use at all in this country.
And it is my belief, based upon observations, scientific
study, curiosity, review of the literature and understanding
this from a much broader perspective, that until we have drug
policy that focuses on all three populations, and until we
begin to do more to address the needs of treatment for people
who have not a controllable disease but a treatable curable
disease, that we will continue to leave ourselves open for
trying to find a band aid solution that in the end does not
address what the underlying problems here. We have not invested
adequately across the full continuum.
Ms. Norton. I appreciate--I think we have a lot in common,
I think, Dr. Barthwell.
Dr. Barthwell. I think we do.
Ms. Norton. Dr. Barthwell does want to concentrate on
prevention, and I commend her for that and for the work that
she has done in methadone. And I agree with her that we ought
to spread methadone. She wants to increase and spread methadone
and do more of it.
Dr. Barthwell, I do ask you to think about the fact that
many communities now have millions of people who are addicted,
and they are our responsibility as well. We have to do--we have
to find something to do about them even if, for the moment, we
say that they have caused their own problem, because now they
are infecting entire communities.
In my own city, two wards, the poorest wards, we now have
equal numbers of women and men with HIV/AIDS. So we are not
prepared to throw away those people and are forced to look at
those who already have the disease as well as the very
important avenue you suggest needs more attention. I thank you
for your testimony.
Dr. Barthwell. Thank you.
Mr. Cummings. Mr. Davis.
Mr. Davis of Illinois. Thank you very much, very much, Mr.
Chairman, and let me thank the witnesses for their patience,
their long enduring time that they have spent.
I think that this issue is one of the most challenging and
most difficult problems facing our country and certainly
perhaps even our world today.
When I think of the large numbers of individuals who, for
any number of reasons, find substance abuse or drug use
desirable to them, or if it is not desirable, they are doing it
anyway--I mean, it alarms me when the Chicago Police Department
suggests that 75 percent of the individuals that they arrest,
or more, test positive for drug use. That's a lot of people.
Or when the county that we live in, Dr. Barthwell, suggests
that there might be 300,000 hardcore drug users in our county.
Admitted, it's the second largest in the country, but
nevertheless, it's still a county.
And, you know, lots of people have different approaches and
different ideas. But I also find that one of the big problems
is that many people do not believe that individuals are
seriously helped, or that treatment really works and therefore
don't want those dollars, their money, their resources, used
for that purpose, even though they don't have any other
solution, or they don't have any other answer.
How effective--and this is something that I am constantly
searching for, because I am constantly trying to convince
people, that we can make better use of our public dollars by
putting them into treatment for those individuals who have
already become affected and put in more resources into
prevention for those who have not, in terms of believing that
we can really head it off. How effective is treatment? I think
we can get more of a handle on that even than we know, how
effective different kinds of prevention are. So that really
becomes my question.
Perhaps we will start with you, Dr. Barthwell.
Dr. Barthwell. OK. We know, over 20 to 25 years of study,
that some treatment is better than none; more is better than
less. The treatment is best when it's driven by assessment,
buttressed with case management and completed with followup
support in their community.
When I started working in this field in Cook County, we--
when we looked at all treatment experiences, someone made an
appointment, had an assessment, was assigned a treatment, made
their first appointment at a treatment provider, and then were
looked at at the end of treatment, looking at the discharge
records of all of those people who had made their first
appointment, whether they made a second or not; 25 percent of
people who were admitted to treatment, opened both clinically
and administratively on the State rolls, completed treatment.
Now that didn't predict in one way or another what they
were doing 6 months, 18 months or 24 months after treatment.
But we know about one out of four people who entered treatment
completed treatment in a positive way.
We also know that we can do much, much better than that.
And in the intervening period, there have been a number of
forces that are external to treatment that have reduced the
length of treatment experience where programs stopped being
program driven in their models and began to respond to
arbitrary lengths of stay for people and discharged them,
whether they had achieved a threshold of improvement in
response to treatment that they could build on in a self-
directive way; once leaving treatment, they basically met the
time criteria and not necessarily therapeutic criteria.
But in programs that are therapeutically driven, that use
national standards for assessment, such as the ASAM placement
criteria, and use them to determine when one has completed
treatment and they are ready to leave, they can get 96 percent
or better sobriety rates 2 years, as documented by urine drug
testing.
We know that if we can get people out 2 years beyond their
treatment experience, using an external locus of control, such
as urine drug testing, that many, many people do better after
that point. Unfortunately, like the needle exchange programs
that might be developed, there will be--there is variance in
funding and support. And most programs that operate in the
public sector don't, in fact, followup on people, don't put
them in a program of external control after they complete
treatment.
So we are not getting the kinds of results that we have the
science and the medicine and the technology and the knowledge
in this country to support.
Now, I think if you looked at the national average, where
you, again, look at all comers and don't discriminate whether
they are hardcore or soft core users, but take all comers, we
are up around the 35 percent completion rate. It's better. But
it is not what we can do if we put our efforts to it.
Dr. Beilenson. If I could, we have studied this in
Baltimore. We do a lot of data-driven stuff. We have a 3-year
study that was done by Johns Hopkins University of Maryland and
Morgan State University that found that, a year after
treatment, whether or not someone was successful or stayed in
the full span of treatment, just all comers, there was a 69
percent decrease in heroin a year later; 48 percent decrease in
cocaine; 69--67 percent decrease in crime; and a 65 percent
increase in illegal income; all of it based on other data
bases. So we were able to check criminal justice data bases,
etc.
In addition--that's the global issues, as Chairman Souder
sort of has been talking about on the AIDS side. In addition,
we run a process called drug stat where, every 2 weeks, my
chief of staff, Melissa Lindamood, and I meet with all the
directors in the drug treament programs in the city--we have 43
of them that have public funding. And we hold them to outcomes;
urines that are positive, improvements in housing, housing
arrest, employment from admission to discharge. And we have
been able to show retention rates in treatment far above those.
Our methadone retention rates at 6 months are about 90
percent. Our non-methadone--our residential retention rates are
at 6 months, because that is the length of the program;
oftentimes, is close to 100 percent. And the intensive
outpatient methadone programs are about 60 to 65 percent.
Rev. Sanders. I am sitting here, and I am feeling very
impressed with the fact--and I hope we are all hearing the same
thing, that there is--I think in the voices, especially when I
listen to Dr. Barthwell, a level of passion about saving lives.
All of us seem to be agreeing that treatment is an essential
part of it.
What I hear as being a big issue for us is how you get
people there. A lot of us talk about these programs we call a
bridge to treatment, that helps us to create another vehicle by
which we get people to treatment that otherwise don't end up
there. Now, the other argument, I think, that has to be dealt
with is the issue of the dollars and the costs.
The fact is that we spend a lot more money incarcerating
people than we do in processes by which we can get treatment
done. I think we ought to begin to think about how we get
people into treatment programs, use diversion and other methods
to get people there. I am not saying that there aren't going to
be consequences, but I am saying the consequences should be
structured such that we get people into the arena that all of
us are agreeing is an essential component in dealing with the
problem of substance abuse and drug abuse and that is
treatment.
I think our dollars can be more well spent. A lot of our
dollars these days are being spent in punitive programs, a lot
of which is going on, in terms of mandatory sentencing and the
like, is translating into dollars being spent in ways that are
not getting us the best return for our money.
I think we got some stuff we are agreeing on here. I am
saying it's important for us to talk about things like about
how do we get people to treatment, and I know that, especially
when I listen to Dr. Barthwell, we were actually intellectually
incubated and on common ground, and I think that we come out
equally passionately committed to people getting treatment.
I think--how do we get people there? I am saying that I
think what we are talking about in terms of some of the harm
reduction models are some very effective ways to do that. I
know that I am not, and I hope that there are not others who
are simply saying this is a vehicle by which we legalize drugs
and by which we bring--that is not their agenda.
Last but not least, just so you understand where I come
from in this. OK, I think people who tout 12-step models have
to agree with me. Addiction is first and foremost a spiritual
problem.
What we are dealing with most, folks caught up in
addiction, people who have dysfunctional belief systems that
cause them to behave in ways that translate into that which is
self-destructive. I think that one of the things that we spend
time doing in terms of engaging folks and getting them into
treatment is to impact how those negative, destructive,
counterproductive belief systems have come to dominate, which I
believe are probably the most powerful things in your life.
And one of the things we try to do is make sure we engage
folks in a way that is translated into that which is positive
but still being constructive.
I spent time doing this for, you know, for all the agencies
in the Federal Government, almost. I do it with people for DEA.
I do it with people for SAMHSA. I do it with people everywhere,
talking about this issue. Because that is what we have to be
about. And I am saying, giving people treatment is where we can
do that. We now have models, we now have programs, we now have
replicable models that can be shared that can help folks do
this effectively.
So I don't want us to lose the point of this issue of how
we get more people to treatment, how we best spend the
government dollar and how we get the result that I think all of
us are looking for, and that is, I think, to save human lives.
Mr. Davis of Illinois. My sentiments, exactly. I thank you
very much, Mr. Chairman.
Mr. Souder. Would you like to close?
Dr. Voth. Just a couple of quick thoughts. I am heartened
to see that the panel and all of you seem very clear in your
legal opposition to legalization of drugs. I just want to
reemphasize, there is a nucleus, maybe not a large one, but
certainly a nucleus that is very powerful that does want to
legalize drugs and is using the harm reduction movement as a
stalking horse to get there. We don't have enough time to get
into details, but it's there, and it's well documented.
One of the things that, as a treatment professional, that
has really bothered me through the years, and I certainly
appreciate, around the table, the difficulties here, and that's
that in-stage, difficult addict that simply can't or won't walk
away.
I think one thing we may have turned to is Sweden, because
they have tried a couple of things in this regard. And
somewhere along the line, we may actually have to explore ways
we extract people from a harmful environment and try to find
almost a mandatory treatment process.
They do have a way in Sweden to take folks who are just so
repetitively harmfully involved and literally remove them from
society and long-term treatment until they can get them back to
a functional state. I hate to see the loss of personal freedoms
in that regard, but then again, you know, where do we juggle
some of those things. Is it more free to be enslaved to heroin
or to be working toward sobriety in some way? I don't have the
answer in that regard.
But I do think that intensifying pressure on addicts,
certainly a continuity of the system, certainly a continuity of
services, works. And one of the things I would love to see in
terms of research--and I am on the CSAT advisory, national
advisory board--is more research directed at looking at the
issue of, can we get services out that entice people into
treatment and sobriety that are at least as good, if not
better, than needle exchanges and services?
In other words, is there really a function in the needle
exchange other than prolonging what we hoped to be getting to
sobriety. I don't know the answer to that. And maybe actually
you have some of the answers to that. But I think that's really
a fundamental question.
Ms. Norton. Mr. Chairman, may I ask a followup question? I
thought there was some understanding in the scientific
community that in order to get people away from drugs, you had
to bring them to the point where they themselves desired--that
compulsory treatment--I don't think you would--this would, of
course, fly in a democratic society in any case, but leave that
aside for a moment. That compulsory treatment would not work
and cannot work. I thought that was the state of the science.
Mr. Souder. Let me supplement that, and rephrase this,
because this is something we have had come up a number of times
in our committee.
Would you say it's safe to say that if a person has
voluntarily made a decision to come, which Dr. Barthwell was
saying, if they show up at the first visit, if they start into
the program, they show up in the next meeting, they agree to do
a profile, to the degree it's voluntary and they want to
change, their likelihood of success goes up?
Dr. Barthwell. Absolutely.
Mr. Souder. But it is not necessarily true that an
involuntarily assignment, for example, to a drug court won't
work.
Dr. Beilenson. That's correct.
Dr. Voth. That's correct, yes, I think all of us would
probably agree on that.
Ms. Norton. To clarify what you said, there will be some
people who will believe you are for taking people, putting them
in concentration camps. You have to be careful----
Dr. Beilenson. No, if I could, coercive treament--I am
someone who has come late to this actually, but it's clear to
me from studies and from working with patients that voluntary--
when you are ready, and there's a window of opportunity, you
are more likely to be more successful.
But coercive treatment through diversion programs in lieu
of probation or in lieu of parole or in lieu of incarceration,
which can be viewed as sort of coercive, can work, especially
if you keep them there for the first 3 months or so in this
program, not concentration camps, but assigned there in lieu of
incarceration or something like that.
Ms. Norton. This is a carrot-and-stick program, so it is
strongly favored, carrot-and-stick program.
Dr. Beilenson. Absolutely.
Mr. Souder. Let me. I want to finish with a couple of
comments, because I actually asked the least questions because
I was going with Dr. Beilenson. I do have a couple of closing
comments here.
One is that I think everybody here in this subcommittee
agrees on treatment. But we don't necessarily agree, Rev.
Sanders, on your formulation that, for example, mandatory
sentencing, which was really intended to address some of the
questions that you raised in racial disparities.
In other words, not letting rich kids who are white be able
to get off for the same crime that a black would be thrown in
jail for. We have talked about that. It may not have been how
it has actually played its way through, but that was a lot of
the intent behind it. And I would argue it probably has reduced
some of the disparities from the past by doing mandatory
sentencing.
I believe that all of us are looking at consequence-based
alternatives, in the sense of drug courts, drug testing, and
other types of testing, but not decriminalization, where there
isn't a consequence that is severe, that causes behavior
change.
Because that becomes this question that we are fencing
around with here, on what Mr. Peterson is saying, what is the
message you are saying underneath this, internationally and
domestically? What is the broader message you are saying in
addition to the practical, trying to address it? If you say
yes, you know, getting pregnant as a teen is wrong, but
everybody does it so let's try to address it here, that's not a
very effective abstinence practice. Same in drugs, it's the
intensity with it. Where is the intensity? You can undermine
that intensity with a follow through.
That is a debate that we are having that is kind of behind
some of this and that, I believe, we need a comprehensive
program in that the bottom line is that, if we don't get the
heroin, poppy and the cocaine and the meth precursors and
everything before they get there, you will be so overwhelmed
trying to treat it you won't begin to handle the number of
people being treated. The people in the community, 75 to 80
percent of all crime, including child-support, child abuse,
spouse abuse, loss of job, are drug and alcohol related. Part
of the reason we put people in prison is to protect everybody
else, including the poor kid at home who has been getting
beaten.
So it isn't just a matter of harm reduction for the
individual; it's also harm reduction for society.
Now we have had a lot of discussion today, and I didn't
mean for it to get this much, and I just read through; it's not
a long book. I am going to ask that this entire document be put
in, all the words of the book, so nobody thinks I am just
quoting out of hand. But first off, a title that says, ``It's
Just a Plant,'' going to kids, is wrong for starters. It's
sending the wrong message.
But I am going to read a little bit of this, because it has
been suggested that we have mischaracterized this book:
Jackie just loved to go to sleep at night. Before she got
tucked in, her mother would help her walk on her hands all the
way to bed. One night Jackie woke up past her bedtime. She
smelled something funny in the air, so she walked down the hall
to her parents bedroom. ``What is that, Mommy,'' asked Jackie.
``Are you and Daddy smoking a cigarette?''
``No, Baby,'' said her mother, ``This is a joint. It's made
of marijuana.''
``Mara what,'' asked Jackie sleepily.
``Marijuana,'' smiled her dad. ``It is a plant.''
``What kind of plant?''
``Well,'' said her mom, ``how about we go on a bicycle ride
tomorrow, and I will tell you all about it. Is that OK?''
``OK,'' said Jackie.
The next day Jackie woke up early to get ready for their
adventure. Then she remembered Halloween.
It goes on a little bit about that.
Then the first trip to the farm where Jackie's mother got
her vegetables.
``Farmer Bob,'' she called out.
``Hi there,'' said the farmer. ``There is a nice costume.''
Then she comes up to a plant called marijuana. So they talk
a little bit about how marijuana developed, marijuana grows
around the world. It can be very, very tall. Is marijuana a
fruit? You could say it is. It makes flowers.
It goes on.
The bottom line, she says,
``Wow, I am going to plant marijuana at home.''
Then the lesson is that children shouldn't use marijuana;
it's an adult thing, and then it goes into--criticize--
marijuana is for adults, who can use it responsibly.
That is not true. It is illegal for adults. It is not
responsible use for adults. That is the legalization argument
that we are making. ``It gives many people joy. But like many
things, it can also make someone sick if it is used too much. I
do not recommend it for everyone.'' It is recommended for no
one. It is illegal for adults. It goes on, and then comes the
conclusion about the importance of changing the drug laws, that
these were imposed by politicians because doctors opposed it.
We used to smoke hemp, which is an anthology. But at the very
end of the book it says, ``This book succeeds in helping
parents send two important messages: Marijuana has a long
history in various uses. And whereas adults can use it
responsibly, it is not to be used by children.''
The fact is, this promotes legalization of marijuana. It's
the thrust of that book. It's an indisputable conclusion.
And Reverend Sanders, it is contrary to your heart and what
you have been saying, and you are secretary of the
organization. We had another board member of the organization
who said he didn't know of this. Then get this off the market,
because it is fundamentally contrary to what you said.
Rev. Sanders. Mr. Chairman, I appreciate your sharing, and
putting the book in the record. Let me just give you a feel for
how these conversations go. It is not unlike what goes on in
conversations with other groups that I end up being a part of,
which I would not belabor. But I have been at the table.
I have been at the table in the board room of the
organization when the conversations went on. As a matter of
fact, I remember when we were doing the mission statement for
the organization, there were some voices there that were
clearly different from mine, but I think one of the reasons why
there is the thoughtfulness in terms of what ultimately drives
the organization, I'd like to think that some of that has to do
with my presence there, just like I think it is important to
have a voice that sometimes counters others. I don't want the
association to be that just because--and I will not----
Mr. Souder. But you don't join a gang in order to try to
change the gang. They are promoting marijuana use in the United
States. We have had hearing after hearing and people have come
up to me and said my mom beat me because she was high on
marijuana. My dad didn't have enough money for that because he
spent it on his marijuana habit. Most people in treatment today
are in fact in treatment for marijuana and not heroin. And you
being on a board that more or less says, look, I'm trying to
influence to be better, you are on a board that is distributing
something that is killing kids in your town.
Rev. Sanders. I guess what I'm saying to you is that I also
serve on a board where if my voice was not in the room there
might be something that you would find much more deplorable.
I'm always in there to be a voice that is counter to. I used an
example a little while ago. I share this again with you. I see
this all the time in my political life because I end up being a
voice at the table that very often has to mitigate on the side
of that which represents human justice, racial equality and
fairness.
As you well know, there are people who will find
organizations--there are people who will find political parties
where they will harbor and find themselves advancing their
agendas. I want to be clear about the fact. But that is not my
agenda, OK. And I guess what I'm saying is I think that my
being present in those conversations is an important part of
what continues to mitigate on the side of what's reasonable
because I do believe harm reduction is a strategy that is
effective.
I do not believe in legalization. I have issues for
criminalization, which I've explained to you earlier, and we
are talking about ways in which we can be better. So I am
saying I don't want to be demonized by saying that is my book
and my position and that's what I'm about. If I did that with
every organization I was a part of, including the Republican
Party, I would be in trouble, so I don't do that. So don't do
that.
Mr. Souder. We are in a very fundamental point here and
this is what Mr. Peterson and Dr. Voth and others of us who
feel so strongly about and this is our argument with George
Soros. There may be some things that work within the movement,
but our skepticism broader is based on this very point, and
that is that you view it that you had this group be less and it
could have been worse. That is why you are on the board and
they do some things that are good.
Rev. Sanders. I do not review the literature and all of
these, so I'm not aware of all of that.
Mr. Souder. What I'm saying is, to me, a book that promotes
to children that it's adult usage and it's OK and misrepresents
the laws in the United States, advocates changing those laws,
says helps you sleep, makes you happy or sleep, that book is
killing people.
Rev. Sanders. If it helps for me to say it this way, my
voice will always be one that speaks on behalf of there being
not anything that advances----
Mr. Souder. I don't mean this in an inflammatory way. Would
you join the Ku Klux Klan group to try to get their policies to
be better? I view this when they are promoting of killing of
people.
Rev. Sanders. So you understand who Edwin Sanders is, I
apply this to every level of my life. One of the ways in which
Metropolitan Interdenominational Church is most well known is
that we were the church that had James Earl Ray's funeral. So
you asked me the question, would I go to a Ku Klux Klan
meeting. I do engage the Ku Klux Klan. I take it to the extreme
because I believe if you're fair you have to do it with
everybody.
I believe that everybody is a child of God. I believe that
everybody is created by the hand of God. I believe that
everybody has infinite worth and value, and I do everything I
can to bring people to the point of Godly lives. I think I'm in
good company and I like the fact that Jesus is often referred
to as hanging out with the sinners, the tax collectors and the
undesirables. I deal with the sinners and the tax collectors
and the undesirables. My purpose is to bring a presence. And I
believe that's a transforming power and I believe that power is
mine through the presence of the Holy Ghost at work in my life
through Jesus Christ. If you want to know it, that's the reason
why I'm there.
I do know that at every Ku Klux Klan meeting they will
stand up and read from the Bible. I have had people challenge
me about being a Christian preacher because the Ku Klux Klan
reads from the Bible. And just like E. Franklin Frazier said
years ago, that religion was the opiate of the people, that
lulled them to sleep instead of being aggressive about the
human rights. And that is what I'm saying.
I'm consistent about this. And I believe it is important to
not shy away from dealing with anybody who does anything that
compromises the value of human life and the God-given right
that all of us should have. That is what America is about and
that's what I'm about, and my voice is always going to be in
those arenas. And I will run the risk that Jesus ran of being
called one of those who associates with sinners, who ends up
with the tax collectors and the undesirables.
Mr. Souder. You have demonstrated to me we disagree flatly
on theology, because Jesus also said that when people do not
hear you should kick the dust off your feet and go to a town
where they're accepted. I would not have had the funeral of
James Earl Ray.
Rev. Sanders. But I think they did hear me. If they hadn't
heard me, you should have seen what the mission statement of
the Drug Policy Alliance would look like.
Mr. Souder. But you are consistent in your views and I
appreciate that and I established that. I disagree somewhat
with those views. I appreciate everyone's tolerance today.
Ms. Norton. Mr. Chairman, can I put on the record that this
book, the name of the publisher of this book is Magic
Propaganda Mill Books. It is not a publisher whom I recognize
and I would like to say, Mr. Chairman, I don't blame you for
your views on this book. I think you would agree with me,
however, that the 99.9 percent of the parents in the United
States of America of every background would find this book
inappropriate for a child and the first thing they would want
to do is keep not only marijuana from their children, but the
knowledge that they have ever smoked a joint in their lives.
And finally, Mr. Chairman, if I may say so, we should not use
things like this, which I think is a royal red herring to smear
all that people are trying to do to get people off of drugs.
I know you remember Joe McCarthy, and some of us would
appreciate this book not being held up to represent people who
are trying to get people to no longer use drugs. I think this
is as marginal as it is possible to be to put this kind of
stuff in a child's book, and I don't think anybody on this
panel----
Mr. Souder. I'm sorry, that is totally unfair. The two
organizations that did that book are both represented before
us.
Ms. Norton. Then I would agree with Reverend Sanders. I
think Reverend Sanders and their councils, telling them
whatever you want to do for adults, you can do, but we don't
want this kind of book out there to appear to condone smoking
joints anywhere near children. So I would agree with you, but
they are not going to listen to us. If he is on the inside, at
least he can get the message there.
Mr. Cummings. Mr. Chairman, we spent the last 20 minutes--
and it just reminds me somewhat of the Clinton hearings where
witnesses would come forward and we would--and they would be
basically criticized up and down after they spent their time
volunteering to come. As I understand it, Reverend Sanders
said, are you familiar with this book?
Rev. Sanders. No. I've never seen the book.
Mr. Cummings. He has never seen the book. One thing, we say
there are two organizations which he may be affiliated with
that put this book out.
Mr. Souder. He is only affiliated with one.
Mr. Cummings. The man doesn't even know about the book.
Doesn't know about the book and we spent 25 minutes now trying
to say--get him to disagree or agree. I don't know what we are
trying to do, but the fact is we heard the testimony and the
witnesses for your side. I respect them. I respect their
opinions and I would not spend one moment trying to disrespect
what they have said. I believe that they come here in good
faith. My friend, the basketball coach, has children back there
or from his team and they have come here and watched his coach
and he has done a great job. I respect that and I respect all
of our witnesses, and that is something we must do.
This is still America. And there has not been--and I have
sat here and I listened to Dr. Beilenson being torn apart
before he even sat down. And these are Americans, all of whom
want to make a difference in the world. They may be coming from
different viewpoints, and that is because they have had
different experiences. So I respect each and every one of you,
and I thank you. And I don't want when people are called to
hearings in Washington for them to feel as if they are going to
be torn apart.
It is one thing for your testimony to be torn apart. It is
another thing for people, us on this side, to be doing what has
been done here today. And I want to encourage people to come
before panels and give their testimony. I want to encourage
them to continue to stand up in their communities for what they
believe in. And this book, the man doesn't even know anything
about the book. And so we have spent all this time doing what
we just did, whatever that was.
Mr. Souder. I respect the individuals and I know that they
are very committed. The fact is when the minority brings
witnesses from the boards of groups that are promoting drug
legalization, and you said earlier that no one favored drug
legalization, you brought representatives from two of the major
drug organizations in the country. Reverend Sanders says he is
fighting internally. I respect him. I think Dr. Beilenson, as
well as the earlier doctor from the first panel, disassociated
themselves with the marijuana policy, but the fact is when you
bring witnesses in from groups that are advocating
legalization, you can expect the chairman to point that out.
Dr. Beilenson. I am only with the city health department. I
am not on any of the boards.
Mr. Cummings. And we will continue down that road that we
just talked about. These are people that are coming here and
testifying, doing the best they can with what they have, and I
believe they are coming from their hearts and they give it
their best. They are affiliated with organizations just like
Ms. Norton said and Reverend Sanders said. Just maybe it is
good to have folk in certain places so they can turn those
organizations around. I appreciate it. We have to agree to
disagree.
Mr. Souder. Thank you. The hearing is now adjourned.
[Whereupon, at 7:05 p.m., the subcommittee was adjourned.]
[Additional information submitted for the hearing record
follows:]