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Return to Galileo? The Inquisition of the International Narcotic Control Board Small, Dan; Drucker, Ernest May 7, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceCommentaryReturn to Galileo? The Inquisition of the International Narcotic Control BoardDan Small*1,2 and Ernest Drucker3,4Address: 1Department of Medicine, University of British Columbia, Vancouver, Canada, 2Director, PHS Community Services Society, Vancouver, Canada, 3Montefiore Medical Center, Albert Einstein College of Medicine, NYC, USA and 4Columbia University, Mailman School of Public Health, NYC, USAEmail: Dan Small* - dansmall@interchange.ubc.ca; Ernest Drucker - emdrucker@earthlink.net* Corresponding author    AbstractNearly 400 years after Galileo Galilei of Florence was arraigned and convicted of suspected heresyby the ten member Congregation of the Holy Office (Inquisition), the International NarcoticControl Board (INCB) is similarly inserting itself into matters pertaining to innovations inhealthcare and the public health response to addiction throughout the world. Like that earlierInquisition of 1633 that convicted Galileo of heresy for holding that the sun is the centre of theuniverse with the earth revolving around it (in contradiction to church doctrine of the time) theINCB and its thirteen-member panel, now rails against any evidence out of sync with theestablished doctrine of the war on drugs – particularly those innovations in public health calledharm reduction.The latest healthcare and harm reduction practices to attract the ire of the INCB Inquisition areelements of Canada's most effective and innovative measures to minimize the harms of drugs inVancouver – supervised injection facilities and, recently, the potential establishment of supervisedinhalation rooms – along with the long established practice of providing safer mouthpieces forpulmonary inhalation in British Columbia. This is particularly significant as it comes in the midst ofa crucial battle between municipal and provincial authorities in BC with the federal government inOttawa, which seems determined to undermine all the most effective HR programs that are theresult of years of steady local and governmental support in Vancouver and now threatens to derailall these programs and spread doubt about their usefulness despite the overwhelmingly positivefindings of serous research.The Grand Inquisitor of the INCB Board, Chairman Dr.Philip Emafo, makes it his practice to issue stern warningsto Canada and all progressive countries that make HRtheir national policy and innovate HR practices. Onbehalf of the INCB Inquisition, Emafo pronounces that allpublicly recant, condemning their leading populationhealth initiatives in addiction work. If they do not, thenthe countries in question are accused of drug policy her-esy.Published: 7 May 2008Harm Reduction Journal 2008, 5:16 doi:10.1186/1477-7517-5-16Received: 13 April 2008Accepted: 7 May 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/16© 2008 Small and Drucker; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 6(page number not for citation purposes)countries must abandon the defense and practice of thedark arts of harm reduction and (like Galileo) must alsoIronically, while the INCB was proclaiming its newestround of objections to evidenced based approaches toHarm Reduction Journal 2008, 5:16 http://www.harmreductionjournal.com/content/5/1/16addiction in the first week of March 2008, at the very sametime the Pontifical Academy of Sciences, with its head-quarters in the Holy See under the direct protection of theSupreme Pontiff was helping to disavow the Inquisitionsof Galileo four centuries ago, momentously announcingits plans to erect a statue of Galileo in Vatican City. Willthe INCB likewise see the error of its ways and recant itsown betrayal of the health and human rights of peoplewith serious addictions? Today we are at a cross roads inCanada – will we defend the truth of evidence-basedapproaches to the pandemic of addiction, by the light ofthe lessons learned from this history, or return to the dark-ness of a time we thought long past?"Whereas you, Galileo, son of the late Vincenzio Galilei,Florentine, aged seventy years, were denounced to this HolyOffice in 1615 for holding as true the false doctrine taughtby some that the sun is the center of the world and motion-less and the earth moves even with diurnal motion; for hav-ing disciples to whom you taught the same doctrine; forhaving been in correspondence with some German mathe-maticians about it; for having published some letters enti-tled On Sunspots, in which you explained the same doctrineas true...We condemn you to formal imprisonment in thisHoly Office at our pleasure. As a salutary penance weimpose on you to recite the seven penitentiary Psalms oncea week for the next three years. And we reserve the authorityto moderate, change, or condone wholly or in part theabove-mentioned penalties and penances. This we say, pro-nounce, sentence, declare, order, and reserve by this or anyother better manner or form that we reasonably can or shallthink of. So we the undersigned Cardinals [Inquisitors]pronounce" (Proceedings of the Inquisition of 1633 pp.288–291)[1]And so it was, in the presence of instruments of tortureand under the formal threat of torture, Galileo was inter-rogated by the Inquisition (a judicial body of ten Cardi-nals) beginning on 12 April 1633 and concluding on 21June 1633 following which he was forced to recant hisheretical views about the nature of the universe on 22June 1633 [1]. The nature of the dispute pertained to thetraditional notion of the earth as geostatic (motionless)and geocentric (at the centre of the cosmos). The view thatthe earth laid motionless at the centre of the universe rep-resented the popular wisdom of the day and had beenespoused since the time of Greek philosopher Aristotle(384 BC – 322 BC) and later formalized by Greek astron-omer Ptolemy (81 to 161 A.D.).With regard to the accepted healthcare responses to addic-tion, we, too, appear to be in the midst of a metaphoricholy war between evidence and belief. But instead of dis-the established doctrine of the war on drugs – a univer-sally failed war militantly espoused by the United Statesand its allies – most cravenly by the Holy Office of Inqui-sition, the International Narcotic Control Board (INCB) –the UN body charged with the responsibility for maintain-ing accordance with drug control treaties and, in so doing,ensuring "adequate supplies of drugs are available formedical and scientific uses and that the diversion of drugsfrom licit sources to illicit channels does not occur" [2]. Infact, the treaties underlie the work of the INCB may betterexamined as religious texts and, as such, the UN may bean inherently challenging area in which to discuss evi-dence [3,4]. But often the Board uses its global pulpit tostifle innovation and intimidate legitimate public healthinnovators in all countries that do not conform to thebankrupt drug wars doctrine stemming back "as far as theLeague of Nations" [2].On Wednesday 5 March 2008, the head of the Interna-tional Control Board Dr. Philip Emafo issued anotheredict on drug addiction from his comfortable position onthe summer side of life at his office in Vienna[5]. Perchedon high in his wingback chair, the INCB head, uponreview of the day's newspaper clippings, once again tookit upon himself to criticize the work of healthcare practi-tioners a world away, this time turning his attention to theVancouver Island Health Authority. Ironically, plans toerect statue of Galileo in Vatican City were announced thevery same week on 7 March 2008 [6]. The statue was com-missioned by the Pontifical Academy of Sciences. ThePontifical Academy is a body comprised of eighty interna-tionally acclaimed academics elected from existing mem-bers and formally nominated by the Pope. The history ofthe institution can be traced to 1603 when it was the Acad-emy of Lincei, one of the first academies of its kind, ofwhich Galileo was a member. This scientific institutionwas renewed in 1847 by Pope IX under a new name as thePontifical Academy of the New Lincei and later renamedunder Pope Pius X1 in 1936 under its current configura-tion as the Pontifical Academy of Sciences. Today, itenjoys the protection by the reigning Pope and maintainsits headquarters in the Vatican where its members assem-ble every year in the Casina of Pius IV [7].Of course, science and beliefs need not be incompatible asPope Paul II stated in a speech in 1992 where he officiallyrecognized the mistakes of the church for having con-victed Galileo for believing that the earth was not the cen-tre of the universe and that it revolved around the sun [6].Still earlier in 1981, Pope Paul II, a pontiff from the home-land of Copernicus, had put in place a commission tostudy the learning opportunities for theologians from thetreatment of Galileo.Page 2 of 6(page number not for citation purposes)pute about doctrine regarding the movements of heavenlybodies, we are embroiled in a momentous struggle aboutHarm Reduction Journal 2008, 5:16 http://www.harmreductionjournal.com/content/5/1/16The current pontiff, Pope Benedict XVI, has publiclypraised the contributions of Galileo.However, these valuable lessons about the relationshipbetween belief and the advancement of human knowl-edge appear to have been lost on the INCB, which rigidlyclings to the outmoded scriptures of the war on drugs andmaintains an open hostility towards evidenced basedapproaches to addressing addiction. In the universe of theINCB, the sun still revolves around the earth at the centreof the cosmos and any opinions to the contrary aredeemed as Heretical. While we, and others, have pointedout that the INCB appears "closed to reason", it does notappear to be either evidence or any thoughtful logic thatguides the actions of this body and its head [8,9]. Like theInquisition some four centuries earlier, it seems moreaccurate to consider the actions of the INCB, and itsInquisitor General, Dr. Emafo, although he is ironicallytrained as scientist, as leading a metaphoric holy war inthe realm of addiction. In this holy war, the Board's doc-trine is American-centric: with its policies revolvingaround the United States federal drug policy with enforce-ment, treatment and prevention as central scriptures:"The Board welcomes the United States Government'sunequivocal policy position against any form of legal-ization of the non-medical use of drugs" [10] (p. 10).There is no book of harm reduction allowed in the UnitedStates bible of drug policy and it fiercely opposes suchinnovations that turn, instead, around local realities andthe need for evidenced based population healthresponses. Like the Church's ferocious attack on Coperni-can heliocentrism championed by Galileo Galilei in 1633,Dr. Emafo and his inquisitors highlight scriptural heresyfor the attention of the Holy Church of the INCB, theUnited States – path breaking programs such as heroinmaintenance, supervised injection facilities[11] ormouthpieces[5] for people addicted to crack cocaine.The most recent innovation relate to the rapid growth inworld markets for stimulants and other drugs that areused by inhalation – in part a reflection of growing aware-ness of the hazards of injecting and its risks for transmis-sion of deadly infectious diseases – HIV and HCV. The factremains that no matter how much we may wish it not tobe, there is a pandemic of smoking and snorting illicitdrugs, such as crack cocaine and crystal methampheta-mine, and that this activity rivals injection drug use inmany countries. But the sharing of implements for smok-ing or inhaling illicit drugs is also now known to be a riskfactor for HCV or HIV [12,13]. Furthermore, it may be thecase that sharing of inhalation equipment may link intra-One of primary risks associated with crack smoking isposed by the use of inadequate pipes. Most crack userscannot afford commercially purchased pipes so they makeuse of metal tubing such as car antennas that transmit heatwhen a flame is applied to the end to vaporize the drug[14]. This technique can result in burned or blistered lips.Crack pipes are frequently shared; the pipes are passedfrom one person to the other with each individual smok-ing some of the drug [14]. When this paraphernalia isshared, bodily fluids such as saliva or blood carrying HCVcan travel between persons [12]. The Hepatitis C (HCV)virus is a significant cause of liver damage in the worldand the related disease processes including fibrosis, cir-rhosis and hepatocellular carcinoma [15]. Of those indi-viduals affected with HCV, between sixty and eightypercent develop chronic hepatitis leading to significantmorbidity and mortality. The smoking of crack cocainecauses blisters, sores and cuts in the mouth which mayalso lead to the transmission of HIV [13]. Once blisters orcuts are created by inadequate pipes or filters, then a fur-ther risk may also be posed through the transmission ofinfected blood through oral sexual activity and the sharingof pipes [14].A second risk is created by the utilization of fragile glasspipes as these present risks in that they crack when heatedor dropped [14]. A jagged glass pipe can cut the lips of adrug user thereby presenting a risk for infection throughexposure to blood when crack pipes are shared betweenpersons. As a harm reduction measure, a safer pipe, madeof heat resistant material such as Pyrex, can be substitutedto reduce likelihood of cuts from an inferior glass pipethat is prone to cracking under heat.A third risk is posed by the use of inadequate filters usedby crack smokers [14]. Furthermore, drug users use copperor steel wool, such as brillo pads, as filters for the pipes.These compact pieces of steel wool are designed for clean-ing pots and pans and often contain detergents. At times,particles of steel wool break off from these makeshift fil-ters and, at times, are inhaled and cut or burn the drugusers' lips. Smoking stimulants such as crystal meth-amphetamine or crack cocaine may also effect the pulmo-nary system leading to lung damage, infection, pulmo-nary edema or respiratory failure [16-23]. The filterpresents an obvious place to intervene with a harm mini-mization strategy by providing a safer replacement.While the risk of death due to injection of heroin is wellestablished, fatal overdoses are not limited to injection[24]. Snorting (intranasal ingestion) or smoking (pulmo-nary inhalation) of heroin can be lethal [25]. Methods ofinhaling drugs can also introduce hazardous concentra-Page 3 of 6(page number not for citation purposes)venous drug using and non-injecting drug using popula-tions.tions of opiate in the blood stream. Risk of death frominhalation (snorting or smoking) may be furtherHarm Reduction Journal 2008, 5:16 http://www.harmreductionjournal.com/content/5/1/16increased when other drugs, such as alcohol, are simulta-neously ingested [24,25]. Lethality may be further ampli-fied by compromised physical health such as decreasedorgan function.There are practical population health responses to therisks outlined above that can mitigate the dangers ofsnorting and smoking illicit drugs. First, flexible and dura-ble mouthpieces need to be provided to cover the tip ofthe pipes so that drug users' lips are not blistered or cut.Secondly, particularly dangerous pipes, such as thosemade out of metal or glass, need to be replaced so that theharms posed by cuts or burns are reduced and in turnreduce risk of the transmission of hepatitis or HIV.Thirdly, the primitive steel wool filters need to be replacedwith a durable and safe substitute that can be inserted intothe end of the pipe without danger of breaking down andposing risks of inhaling chemical detergents and metal orbeing cut by shards. Fourth, the potential overdoses fromintranasal or ingestion of stimulants (e.g. heroin, crackcocaine, crystal methamphetamine) could be mitigatedthrough the provision of a supervised inhalation facility.A supervised inhalation facility would provide the oppor-tunity for a highly marginalized group of drug users to bebrought into the doorway of healthcare where they canhave access to harm reduction, preventive populationbased health innovations, treatment, detox and supportedhousing.In Canada, in partnership with the Vancouver CoastalHealth Authority, the PHS Community Services Societyoperates a Supervised Injection Facility (SIF). While theSIF and other programs provide a desperately neededentry level of health engagement for people with activeaddictions who inject illegal drugs, there are still severalthousand people in British Columbia that are addicted toillegal drugs (such as crack cocaine or crystal metham-phetamine) that are smoked. Currently, this group of peo-ple is still forced to use drugs in open public spaces andunsafe environments where access to housing, health andtreatment services are minimal.The aim of the harm minimization efforts such as the pro-vision of mouthpieces or a supervised inhalation pilotwould be to match the positive effects of the supervisedinjection initiative by reaching a target group that is oth-erwise unengaged in any form of medical or support serv-ices in order to reduce the harms associated with smokingcrack cocaine and crystal methamphetamine while dra-matically reducing public disorder and open drug use. InBritish Columbia, medical and public health authoritiesand practitioners had established a standard of care forone group with serious needs (those who inject drugs),jurisdictions including Canada, the distribution of peoplewith serious addictions who inject is roughly the same asthose who inhale. In some settings, the numbers of thosewho inhale drugs are overtaking those who inject.The Mayor of Victoria Alan Lowe [26], the Victoria IslandHealth Authority[26], the Chief Medical Health Officer ofB.C. (Dr. Perry Kendall)[27,28] and the VancouverCoastal Health Authority[29] share the view that thereneeds to be a variety of strategies to engage the equallymarginal group of people living with active additions whosmoke drugs such as crack cocaine or crystal methamphet-amine. In fact, provisions for the purchase of mouthpieceshave been made in provincial budgets since 2007. Indi-vidual health authorities determine the provision of theseharm reduction items.There is also a need to go still further in reaching peoplewith addiction to smoking stimulants such as crackcocaine and crystal methamphetamine. There is a need toestablish a supervised inhalation pilot in British Colum-bia. The international standard of practice for safer con-sumption rooms is to operate supervised injectioninitiatives together with supervised inhalation programs.By way of example, there are 12 safe consumption facili-ties in Switzerland. Of these, eight have spaces for injec-tion and inhalation. Similarly, there are 22 safeconsumption facilities in the Netherlands. All of themhave space for both injection and inhalation. In Germany,there are 25 consumption rooms with 13 providing spacefor inhalation as well as injection[30].In the Canadian setting, we have established a standard ofcare for one group with serious needs (those who injectdrugs), but inadvertently excluded the needs of an equallyneedy target group (those who inhale or smoke drugs).We believe that a supervised inhalation room needs to beopened as soon as possible to resolve this disparity byreaching the equally marginal group of people living withactive additions who smoke drugs such as crack cocaine orcrystal methamphetamine. A second research pilot needsto be launched that examines the ability of a supervisedinhalation initiative aimed at reaching a target group thatis otherwise unengaged in any form of medical or supportservices in order to reduce the harms associated withsmoking crack cocaine and crystal methamphetaminewhile dramatically reducing public disorder and opendrug use.Concluding thoughts: a return to GalileoFar removed from the suffering of people with addictionsin the shadows of life, the INCB Grand Inquisitor judgesadherence to drug policy scriptures and keeps a watchfulPage 4 of 6(page number not for citation purposes)but inadvertently excluded the needs of an equally needytarget group (those who inhale or smoke drugs). In manyeye out for heresy. In formal terms, the INCB has all theferocity of a papier-mâché tiger in matters of publicHarm Reduction Journal 2008, 5:16 http://www.harmreductionjournal.com/content/5/1/16health. Apparently ferocious, upon careful inspection, thispolitical body poses no serious threat to legitimate initia-tives aimed at welcoming people with serious addictionsinto the doorway of healthcare, like the provision ofmouthpieces to combat HCV or supervised injection facil-ities to combat epidemics of HIV and overdose deaths. Butthe real danger they pose is through insidious politicalinfluence – giving comfort to the local enemies of suchprograms and, more significantly, offering a seemingly (ifnot actually) authoritative international voice for retro-grade policies that fly in the face of both scientific evi-dence and humane concerns.Through their totally illegitimate political influence, theInquisitors of the INCB now threaten to undermine thecomprehensive approach to addiction in Canada – anapproach that has become an international beacon ofprogress. This approach is based on the principles andbest practices of harm reduction and includes some of thebest and most innovative treatment and prevention pro-grams for addiction in the world – e.g. easy to access todetoxification, supervised injection facilities, needle dis-tribution programs, pharmaceutically assisted therapies(methadone, heroin, stimulant replacement under a phy-sician's care), safer crack-pipe mouthpieces, effective pre-vention and thoughtful enforcement then too manyparents will be saying their final goodbye to their son ordaughter at the funeral home due to overdose or theunfortunate reach of the Hep C and AIDS pandemic.Through these efforts Canadian healthcare professionals,now have access to the best tools for the medical tool-belt,even if it contradicts the scripture of the American war ondrugs.The real question here is how we will return to the lessonsof Galileo. Debate pertaining belief, the evidence base andthe best way to move forward with best practices foraddiction medicine and healthcare are, of course, legiti-mate. But we have to remember that no single tree growsto heaven when it comes to addiction. There is not onlyone approach and unsure cures are sometimes better thanno cures at all. We need many approaches and innova-tions to approach the various forms of serious and persist-ent drug addiction. Fortunately, the INCB, we have toremember, is not the United Nations. Nor do they repre-sent the United Nations. The creation of the INCB can betraced to three treaties, the Single Convention on NarcoticDrugs (1961), the Convention on Psychotropic Sub-stances (1971) and the United Nations Conventionagainst Illicit Traffic in Narcotic Drugs and PsychotropicSubstances (1988)[2] The INCB has a limited responsibil-ity to ensure that adequate supplies of narcotic drugs areavailable in the world for medical and scientific use andconcerned with the international and national monitor-ing and management of illicit and licit drugs. Despitemedia reports, the INCB is not the United Nations. TheUnited Nations readily recognizes the need for efficaciousand evidenced-based action with respect to the AIDS pan-demic and, as such, the United Nations General Assemblyunanimously publicly declared the importance of harmreduction on 2 June 2006 [31].Far away from comfort of the comfortable offices of theINCB Grand Inquisition in Vienna; healthcare, housingand service providers are earnestly attempting innova-tions amidst the shards of broken dreams. We must notfalter, despite this attention from the shadowy pressurefrom the INCB, to work towards developing evidencedbased healthcare innovations in response to each newphase of addiction as they unfold.In contrast to Galileo who aimed his telescope at the skies,those of us who walk down the old and dusty road ofhealthcare are focusing on more earthly problems and, inso doing, trying to help alleviate the burden of sufferingfor real people, their families, and society at large. In thegeostatic world of the INCB Inquisitors, with the UnitedStates drug policy at the centre of the cosmos, the worldmay indeed be either black or white. But for those health-care practitioners and service providers trying to cobbletogether effective strategies to address the pandemic ofaddiction, there are, by necessity, many colours in thespectrum of social problems.In the moral borderland of addiction, it is sometimes eas-ier to burn metaphoric bridges than to build them. And inthe world of the INCB, perhaps, those countries andhealthcare practitioners who practice harm reduction areexpected to prepare a solemn recantation such as Gali-leo's:"I, Galileo, son of the late Vincenzio Galilei of Flor-ence, seventy years of age, arraigned personally forjudgment, kneeling before you Most Eminent andMost Reverend Cardinal's Inquisitors-General againstheretical depravity in all of Christendom, havingbefore my eyes and touching my hands the Holy Gos-pels, swear that I have always believed, I believe now,and with God's help I will believe in the future all thatthe Holy Catholic and Apostolic Church holds,preaches, and teaches...I have been judged vehementlysuspected of heresy, namely of having held andbelieved that the sun is the centre of the world andmotionless and the earth is not the centre andmoves...I, Galileo Galilei, have adjured as above, bymy own hand" (Proceedings of the Inquisition ofPage 5 of 6(page number not for citation purposes)identifying limitations in controls that lead to the sale, useor manufacturing of illicit drugs. The INCB is primarily1633 pp. 292–293) [1]Harm Reduction Journal 2008, 5:16 http://www.harmreductionjournal.com/content/5/1/16For the INCB Inquisitors, it is relatively easy, from afar, tocondemn the earnest efforts of healthcare providers whoattempt however possible to engage marginalized popula-tions of people with addictions in the doorway of health-care. The INCB appears hell-bent on trying to ignitepolitical fires and this is sometimes disheartening for eve-ryday people working at the local level. Perhaps, we are allnaively traveling up a long and lonely stream promotingthe idea that addiction is a matter for the Chief of Medi-cine rather than the Chief of Police and it is time for us toprepare our renunciation of all harm reduction for theINCB Inquisitors. But we think not.After all – still under threat from the Inquisition – evenGalileo got out the words of the need for truthfulness inscience. And while there is no definitive proof that at thistime he whispered, "Eppur si muove" ("And yet itmoves")[32] he did write in a Letter to the Grand DuchessChristina in 1615:"However, I do not think one has to believe that thesame God who has given us senses, language, andintellect would want to set aside the use of these andgive us by other means the information we can acquirethem, so that we would deny our senses and reasoneven in the case of those physical conclusions whichare placed before our eyes and intellect by our sensoryexperiences or by necessary demonstrations [emphasisadded]"[1] (p.95).In the face of the physical conclusions of harm reductionthat have been placed before our eyes and intellect, willwe in public health and medicine do any less and forgo(or recant) the evidence base seen by our own "senses,language, and intellect"? We think not-ever again!Competing interestsThe authors declare that they have no competing interests.Authors' contributionsDS wrote the first draft. Both authors participated in thewriting of the manuscript and approved the final version.AcknowledgementsNo funding was obtained in association with the writing of this commen-tary.References1. Finocchiaro MA: The Galileo Affair: A Documentary History.Berkeley , University of Berkeley Press; 1989:288-291. 2. INCB: International Narcotic Control Board: Mandate andFunctions.   [http://www.incb.org/incb/mandate.html].3. Bewley-Taylor DR: Challenging the UN drug control conven-tions: problems and possibilities.  The International Journal of DrugPolicy 2003, 14:171-179.4. Cohen P: The drug prohibition church and the adventure of5. Edwards S: 'Crack Kits' initiative specifically mentioned in nar-cotics control board report.  In Times Colonist Victoria ; 2008:A3. 6. 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