Cohen, Peter (2003), Harm refusal. Making peace with cocaine, and advancing from harm reduction to harm refusal. Presentation at the Foro Social Mundial Temático "Democracia, Derechos Humanos, Guerras y Cultivos de Uso Ilícito", Cartagena de Indias, Colombia, June 16-20, 2003. Amsterdam: CEDRO Centrum voor Drugsonderzoek.
© Copyright 2003 Peter Cohen. All rights reserved.


Harm Refusal

Making Peace with Cocaine, and Advancing from Harm Reduction to Harm Refusal [1]

Peter Cohen

I'm sorry that I cannot speak in Spanish. I will try to be clear in English. First I want to say, in agreement with Marco Perducca, that I am very happy to be here in Colombia and thankful for the invitation of Mama Coca. My speech will try to clarify a few issues concerning cocaine use.

What is cocaine? More precisely: how is it used, and how do we apply theories to describe the use of cocaine? A second topic that I want to discuss is the topic of discrimination: How drug policy constructs itself as a mechanism of discrimination. And the third topic that I want to explore is the uses and limitations of harm reduction. Perhaps we will require a wider view of the concept of harm management, one which includes what might be called harm refusal.

Let me start with the use of cocaine. Yesterday Anthony Henman spoke about making peace with Coca, with the leaf of Coca. We cannot make peace with the leaf of Coca if we also do not make peace with cocaine, the principal alkaloid of the coca leaf. And in order to make peace with cocaine, we must suspend all preconceptions about “cocaine - the drug”, about how we evaluate and talk about the use of cocaine; we must carefully evaluate the available scientific data and allow our findings to guide us towards that peace. In order to illustrate the ways in which we look at cocaine use, I will use two contrasting examples from the scientific literature.

The first example is a book that was published about two years ago by a Belgian criminologist, Tom Decorte [a]. It is a thick book, almost 500 pages, which discusses all the research that is available about the use of cocaine among people from the general population — users we can find amongst us in everyday life. There is, in fact, an astonishing amount of research on cocaine: in the Netherlands, in Belgium, but there is also research on cocaine use in the populations of Canada, Australia, the United States, and England. Decorte puts all this together and, what are his conclusions? His conclusions are that the large majority of cocaine users use the substance for a relatively short period of time. They use cocaine mainly as amplifiers of social pleasures. So this means that cocaine is used to go out to the disco, or to chat with your friends, or as a dessert after dinner. Most cocaine users use small to moderate amounts of the drug because otherwise the pleasure of cocaine becomes distorted. For most users large does of cocaine are not pleasurable. It's a little bit like alcohol: For most users, too much alcohol is not pleasurable. Decortes’ conclusions are quite complicated and, if you really want to know more about it, a careful reading of the book is essential. What he says is that the disadvantages and the dangers of cocaine seem to have been described in a very highly overstated way. Decorte doesn't touch on the question why this is so. Why has science overstated the dangers of the use of cocaine for such a long time? That is a question that I want to touch upon here after referring to a second example from the scientific literature.

Herbert Kleber, a psychiatrist working in United States with F. Gawin, has also been publishing work on the use of cocaine. In contrast to the samples of users that are described in Decorte’s overview, Gawin and Kleber have done research on users who ended up in the drug treatment system of the United States [b].

Now it is evident that if you look at drug users that have ended up in the treatment system, you necessarily focus on patterns of use, and motivations of use, that are completely different than for the great majority of the users of the drug. Looking at clinical samples, you come to completely different conclusions about the effects and possible ‘dangers’ of the use of cocaine than when you focus on general population samples of cocaine users. Basically, what I am saying here is that the dominance of medical and psychiatric perspectives on the use of the drug has created types of research focused on clinical cases, and that this has completely distorted our capacity to understand the nature of the use of cocaine in the general population. The same has been true with opiates but I will not discuss opiate research here.

In other words, we see what we want to see. Or, we see what we are made to see, determined by the type of ‘scientific eyes’ that concoct the view that makes it to the public domain. And what we see is to a high degree determined by preconceived ideological convictions that we have about the use of the drug. If we have learned — and most of us have learned this all our lives — that cocaine use can be highly dangerous, we will much more readily believe research that appears to legitimise those prejudices. The research that comes from clinical settings is usually able, both by its sample and by the type of questions it presents, to legitimise preset ideas about the dangers of cocaine. If you work as a sociologist — I am a sociologist — and you want to see cocaine use as a much wider phenomenon than only limited to clinical cases, you see a completely different image of the use of cocaine. For instance, in the many projects that my research centre (CEDRO) initiated on cocaine-use patterns over time, we included research on how people use cocaine over a 10-year period. We did not see anything that you see in clinical research. We see that after 10 years, 60 percent have stopped using cocaine because, we assume, their lifestyles have changed! The functionality, the usefulness of cocaine in a socially outgoing lifestyle has diminished, or even disappeared. Sixty percent of cocaine users have quit after 10 years in Amsterdam — and in other cities the figures are similar. So we have to rectify our preconceptions of the use of cocaine and see it as only a very limited risk for a very limited period in a user’s life. I say this because we need to have this knowledge and have to apply this knowledge, if we somehow want to make peace with cocaine and not only with Coca. Of course, if cocaine were available as a licit drug, we might see the development of other use careers or more users. However, the probability of this to happen is low: the availability of cannabis in the Netherlands as a semi-legal substance has not made the Netherlands into an area with the highest level of use in Europe or the development of extra high intensity use patterns. [cd] Ergo, culture and economic conditions determine use levels of a drug much more than ‘legal’ availability.

I said that I would speak about discrimination and, since Cartagena — I'm told — has been one of the centres of the Spanish Inquisition in Latin America, I would like to use the example of Inquisition to describe how we philosophically create the phenomenon of discrimination. In the theory of the Inquisitors, people who would deviate from the road of ‘rightly’ speaking to God, and from how to ‘rightly’ interpret the Bible, or from the ‘correct’ road to acquire God's grace, those people — intentionally or not — dehumanised themselves. Their soul could no longer be saved; they would not be able to aspire for the highest goal of a human, that is, to accept God’s grace and in the afterlife be in paradise. So these people could be treated as non-humans! And we see in the whole history of discrimination in the world, be it around race, around class, around faith, the dehumanising of the other is one of the central aspects. Dehumanising the other is the most essential process to understand how some sorts of discrimination can become so violent. On the basis of highly selective images of cocaine users and highly selective types of research, we could say that we have chosen to treat cocaine users as people who have intentionally or unintentionally deviated from the highest aspirations of humankind.

Our modern ideology about the human individual’s highest goal is no longer that he accept the grace of God but rather that he realise his ‘individual potential’. We have learned to look at cocaine use as a deviation from that highest aspiration. The possibility of so-called addiction makes all cocaine users into human beings who no longer aspire for this highest goal: individual autonomy and individual responsibility. Thus are we able to take away one of the most basic aspects of their humanity, and this is even more valid for people who sell cocaine. People who sell cocaine are seen as evil agents. They induce others to forfeit their highest individual qualities. We can dehumanise them; we can do anything to them. For cocaine producers, exactly the same applies. As long as we apply these highly discriminatory philosophies to users of cocaine, or dealers of cocaine, or producers of cocaine, we legitimise the brutal and medieval policies that we apply to these people in some of our countries.

In the United States, the average number of prisoners per hundred thousand has quickly risen since the 1980s, from around 120 to over 700. Over 700 people per hundred thousand are in jails and prisons in the United States compared with an average of around 100 in the European Union. The scale of imprisonment of American citizens by their government — on the basis of crime politics and on the basis of a particular vision on drug use — is simply incredible. We have to realise that the U.S. politics of discrimination that give rise to idiotic policies such as Plan Colombia not only endanger the security and human rights of people outside the United States, but also threaten those inside the United States. These philosophies of dehumanisation have created brutal legal conditions for the US population as a whole, and certainly for its minority populations.

Where does this lead me? I was asked to discuss today something about harm reduction as well. As you all know, harm reduction has been a very fashionable philosophy for setting up drug policies. But looking at the highly discriminatory characteristics of drug policy, we could also say that harm reduction is too limited to meet the political problems that discrimination-based drug policy creates for us. Maybe we have to move to a different philosophical position and say that some of the harms that are created by our discriminatory drug policies can no longer be accepted and included in a scheme to reduce these harms. I would say that the incredible rate of imprisonment in the United States is one of those harms that we cannot accept. The intolerable damage inflicted on third world drug producers are merely the side effects of trying to keep illicit drugs out of the United States or the European Union; this damage is simply not acceptable. We have to develop ideas about harm refusal. Human Rights are of course the philosophical background against which we can judge those harms and I think that is what we should apply. Harm reduction is relevant for certain social conditions and for certain political contexts. However, the power of the police in the United States is truly excessive, as is the harm done by them. The power of military forces enforcing drug laws in countries in Asia and here in Latin America is simply unacceptable. In some areas of drug politics we have to move from harm reduction to harm refusal.

The history of harm reduction in Europe is a long one. Originally harm reduction was an expansion of the thinking in the area of public health. Once you accept drug use and some of its effects as public health problems, you can attack them as public health issues. If an infectious disease is thought of as a public health problem, you can then try to reduce the rate of infection. Considering the disease as a crime problem would be very strange and only understandable in a moralistic interpretation of infection. The background of syringe-exchange programs is: reduce the rate of all sorts of infection. In the Netherlands, harm reduction has gone a little further. As a result of refusing to chase small-time dealers in heroin, the price of heroin in the Netherlands decreased quickly in the 1980s. The Netherlands became the country where heroin was the cheapest in all of Europe. And this created the possibility for people who were using heroin — which were not very many, at maximum 0,2 percent of the population — to switch from injecting to smoking heroin. The entire market changed. By creating the conditions that made heroin cheap, it was no longer necessary to inject heroin; it could simply be smoked. And by the acceptance of the cultural habit of smoking the drug, a whole area of risk behaviour simply no longer existed. All the problems of injecting were highly diminished. But there is a limit to this type of harm reduction. People can still be sent to prison in the Netherlands for heroin related crime and the answer to that was, at a certain moment in the 1990s, to say "OK let's take away the possibility of people ending up in prison, being arrested for dealing, or smuggling or stealing. Let us no longer accept the harm of criminalization and imprisonment. Let's give them heroin." So at the moment, heroin distribution and heroin maintenance is the latest policy innovation in the Netherlands in the area of heroin use. But, where do we go from there? If we allow users to get heroin from a legal source, either buy it or get it for free, haven't we legalised heroin? In a certain sense we have. If you look at the progression in harm-reduction programs in the Netherlands and in some other European countries, you can say that the evaluation of the concept of harm and the refusal to accept particular types of harms, have logically led to semi-legalisation of heroin for a considerable proportion of its users.

If we stopped trying to reduce some types of harms but instead evolved to a position of not accepting them (however reduced), we would logically end up by finding schemes for legalising the use and the production and the distribution of these drugs and we will be forced to look at the use and production of those drugs with more realistic perspective and more generalisable scientific theory.

Thank you very much.


  1. I thank Peter Webster profusely for editing the transcribed text (transcription Maria Moreno). The original can be found on the Mama Coca website:
  1. The taming of Cocaine: Cocaine use in European and American Cities, Brussels, VUB University Press, Series: Criminological studies, 2000, 499 p. ISBN: 90 5487 284 5.
  2. See for instance F.H. Gawin and H.D. Kleber, Abstinence symptomatology and psychiatric diagnosis in cocaine abusers: Clinical observations. Arch. Gen. Psychiat. 1986; 43-107
  4. Peter D.A. Cohen, Hendrien L. Kaal (2001), The irrelevance of drug policy. Patterns and careers of experienced cannabis use in the populations of Amsterdam, San Francisco and Bremen. Amsterdam, CEDRO.