[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:]





                                 
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