Dr Ayesha Mian, Medical Advisor | The Centre for Medicinal Cannabis
The cannabis plant is among the most versatile in the world. For millennia, it has been used across cultures as a way to socialise, provide food, textiles, shelter and as medicine. The endocannabinoid system that the plant interacts with is so essential to life that it can be found in every vertebrate. And yet in the last century we have erased the history of cannabis and demonised its use. It has been weaponised against the poor, people of colour, women, children, and those who are ‘different’. A plant has become a tool of oppression. By driving it underground, prohibition has caused untold harm in society and we have lost decades worth of scientific discovery. It is an injustice on many levels.
The pandemic has worsened pre-existing health inequalities. In the UK, Black and minority ethnic groups (BAME) consistently had higher rates of mortality compared to white counterparts.1 The recent Build Back Fairer report concluded: “[The] most damaging impacts have been for young people, low paid workers, BAME groups, disabled workers, women, part time workers, and the self employed.”2 The North, the Midlands and coastal towns in the South of England host the areas of most deprivation. These regions and communities struggled before the pandemic, but COVID-19 exacerbated their challenges, a result of a decade of disproportionately higher cuts to local services in areas of greatest need.
The pandemic created a syndemic which “exists when risk factors or comorbidities are intertwined, interactive and cumulative—adversely exacerbating the disease burden and additively increasing its negative effects.”3 Addressing the complexity of these associations are now better recognised by many healthcare agencies. Focusing on the Social Determinants of Health (SDH) (see box 1), cross-sectoral integrated approaches to reducing inequalities, have become core priorities in several national agendas,4 including the NHS’s new Long Term Strategy.5
Without understanding the impact of drug policies on SDH, the newly emerging UK medical cannabis industry will continue to exacerbate the inequalities we are trying to overcome. Areas and people most affected by the pandemic are also most easily targeted by violent gangs related to drugs crime. They are being deprived of the opportunities, educational, social and economic, to develop the resources and skills needed to thrive in a technologically advancing world. Practicing in the field of medical cannabis requires a high skill set and patients require access to medicine. With expensive private clinics, many people most impacted by drug control are excluded from accessing cannabis’s therapeutic benefit and left unprotected from its illicit market harms.
Without understanding the impact of drug policies on social determinants of health, the newly emerging UK medical cannabis industry will continue to exacerbate the inequalities we are trying to overcome.
Globally, import of medical cannabis from developing countries where production costs are cheaper poses risks of exploitation of local communities and economies. Even in the UK, Vietnamese people, especially children, are trafficked into slave labour on illegal cannabis farms.6 7 Young people across the country are easily recruited into county lines drug trafficking networks when faced with dwindling educational and economic opportunities.
Dame Carol Black’s recommendations of her independent review8 informing the recent Ten Year Drug Strategy acknowledged the need for a ‘whole systems approach’ tackling the profit-driven harms of illicit drugs trade through prevention. However, it does not recognise that many people who engage with the illicit market for cannabis use may be among the estimated 1.4 million patients caught in the middle of the drugs trade. These people put their health and safety at risk while engaging with the illicit market to access their medicine, because private clinic options are too expensive and hard to access. This is unacceptable.
Black, Asian and Minority Ethnic (BAME) people who are four times more likely to encounter law enforcement in terms of being stopped and searched for drugs. According to the pressure group Release: “Low level cannabis possession offences drive this disparity, with an estimated one in three of all police searches for cannabis possession alone.9” There is almost no research into the effect of drug policy on medical cannabis access for BAME and other groups disproportionately affected by prohibition.
Lord Simon Wooley argues for more advocacy from doctors on this issue, writing in the British Medical Journal: “In its implementation, prohibition has provided the opportunity and alibi for decades of harassment and over policing of black communities. It provides one of the very sharpest tools in the box of systemic racism: enabling police to use the flimsiest of pretexts to search and arrest black people, thus allowing wider society to associate black people with all the violence and exploitation that prohibition creates in the drug supply chain. It also intersects with poverty, exclusion, and health inequalities, creating cycles of harm that become hard to break.”10
The reawakened interest in cannabis as medicine is failing to develop an industry aware of its past and the urgency to incorporate equity and fairness. There is almost no attempt to address the British historical narrative in shaping the inequalities we see today (see box 2). If this is analysed and incorporated into regulation and industry development, we will avoid past mistakes and can create solutions for equitable progress. The medical cannabis industry in the UK struggles to platform diverse communities, including patients and advocates, most affected by prohibition. There is an asymmetry of knowledge between patients who have researched and utilised cannabis medicinally from illicit sources, and medical and industry professionals relatively new to the space.
To rapidly advance progress in the industry, it is imperative to support patients and incorporate the knowledge they have into research for better therapeutics. They should not be at risk of criminalisation and instead integrated into an equitable reform of regulation. Human rights lawyer and key proponent of the knowledge equity movement11 Baljeet Sandhu states “If we don’t think about the knowledge that is present in all our communities we will continue to privilege the few as knowledge producers and see them as having a larger stake in how we design the future.”12
The complexity of studying endocannabinoids lies in their interaction with every system in the body. Difficulty translating this complexity has led to widespread misinformation on purported benefits and risks. Many medical cannabis companies have tried to fill the knowledge gaps among medical professionals. Unfortunately, this encourages cynicism against undue private influence over prescribing. It also complicates access to knowledge for health professionals who may be time and money restricted, hesitant to invest in costly unregulated information. The companies have good knowledge of their products but there is a need for a regulatory body that can impartially assess how this knowledge is integrated into medical learning. It is vital to develop a standardised, professionally accredited curriculum that consolidates global knowledge and best clinical practice.
The UK is also at risk of missing out on health innovations based on plant therapeutics. Plant based medicines such as cannabis provide an opportunity to pilot innovations in integrated, personalised healthcare. Progress comes through experimentation, and we must dare to explore new avenues to maximise health and wellbeing. We must be allowed to fail safely.
It is vital to develop a standardised, professionally accredited curriculum that consolidates global knowledge and best clinical practice.
In terms of production and supply, diverse participation in the knowledge and policy making process is the goal and should be encouraged through an Institute of Pharmacognosy. This institute can issue guidance for the fair production, development and distribution of medical cannabis among other plant-based medicines. Knowledge networks based on diverse collaboration can support oversight into technologies utilised in drug development, such as ethical Artificial Intelligence.13 14 It can provide additional support for new treatments, and improving accessibility into the industry, supporting skills development and technical assistance.17 18
Through equity-based internships and mentorships at medical cannabis companies and research groups it is possible to solidify an industry pipeline. Support for local enterprise is also key. Levelling the playing field for small and medium businesses in the UK should include extra support for people who face disproportionately higher barriers to access in the context of enabling social and economic equity.
Developing processes to ensure minimal environmental impact from production and distribution will ensure a fair chance for British based businesses to compete locally and internationally, for example by enabling more domestic cultivation. Communities most affected by drugs should also have priority in shaping the industry. To reduce the harms and maximise the benefits around cannabis, all stakeholders should be involved in developing regulation.
The UK has a unique advantage to establish an industry based on the wisdom of lessons learned from past mistakes. It can once again lead in scientific discovery around plant-based therapeutics. Emerging markets around the world lack reconciliation between past and present, licit and illicit. Now the UK has an opportunity to become a global leader in modelling equity-based cannabis regulation. We should establish a legacy that future generations can be proud of. This is our chance to build back fairer.
10) British Medical Journal (BMJ) 2021;374:n2147
Murphy, K., Di Ruggiero, E., Upshur, R. et al. Artificial intelligence for good health: a scoping review of the
ethics literature. BMC Med Ethics 22, 14 (2021). https://doi.org/10.1186/s12910-021-00577-8
14) British Medical Journal (BMJ) 2020;368:l6927
18)There are many organisations in the US and Canada focused on equity in cannabis, including those led by doctors such as https://www.achemed.org/. These organisations have already articulated many key lessons UK can incorporate into its own regulation.