Bolivia, is still stuck in the prohibitionist dark ages. But that hasn’t stopped some patients from seeking medical cannabis treatments, despite the nation imposing some of the harshest cannabis penalties around, with users facing up to 25 years in prison if caught. Here we head deep into the clandestine medical cannabis market that so many Bolivian patients have come to rely on.
Pablo’s head is furrowed with scars. The most visible ones are on top of his neck and around his ears. Not even his thick, stiff black hair conceals them. They are a reminder of the worst falls this 17-year-old teenager, who was diagnosed with West Syndrome before his fifth birthday, has suffered. The disease, which affects 1 in 4,000 to 6,000 births, is a type of epilepsy (epileptic encephalopathy) that causes spasms, delayed mental and psychomotor development, and high-voltage wave discharges (hypsarrhythmia on the encephalogram). The latter are the seizures that assault Pablo up to 15 times a day and force his mother, Hortensia, to be alert at all times to the steps of her eldest son. The worst ones knock him to the floor, sometimes on his back, sometimes on his face, and injure him severely. They have left fractures in his nose, broken teeth, wounds in his eye, and scars that furrow his head.
Pablo’s name is not Pablo. Hortensia is not called Hortensia, either. Their real names have been changed for this report, not because they feel any shame about their lives and scars, but because she once had the audacity to give her son cannabis oil to reduce his seizures, his falls, and the wounds on his head.
The Risk: 25 Years in Prison
In Bolivia, cannabis (popularly known as marijuana) is a controlled, illegal, and criminalized substance. Its production, processing, and sale are prohibited, as is its consumption, which does not distinguish between recreational and medicinal uses. Law 1008 of the Coca and Controlled Substances Regime, in force since 1988, cares little or nothing if someone uses cannabis to get high from a joint or if another seeks it in the form of oil to alleviate chronic pain in a close relative. If found in possession of the product, both can be arrested, sent to a court of law, and, depending on the amount of the drug seized, pay for their “crime” with a period of rehabilitation or up to 25 years in prison. Bolivia is one of three countries in South America (along with Brazil and Venezuela) and one of nine in the entire American continent where cannabis consumption is illegal, regardless of whether it is for recreational or medicinal use.
A Prohibitionist Hangover
Articles 46, 47, 48, 49, 50, and 51 of Law 1008, created under the influence of the “war on drugs” promoted by the United States, criminalize the planting, manufacture, trafficking, consumption, and possession for consumption, administration, and supply of more than 100 controlled substances, including narcotics, psychotropic and chemical substances distributed in five different lists (based on the protocols of multilateral organizations such as the UN). Schedule I narcotic drugs include cocaine, cannabis, and its resin.
The above-mentioned articles establish sentences of 1 to 2 years of imprisonment for those who plant the substances, 5 to 15 for those who manufacture them, 10 to 25 for those who traffic them, internment in a drug addiction institute for those who consume and possess them for consumption, 10 to 15 years of imprisonment for those who administer them and 8 to 12 for those who supply them. Although, in principle, the crime of consumption and possession for consumption would only be punished with rehabilitation, it further provides that if the possession, to be determined by “two specialists from a public drug addiction institute,” is “greater than the minimum amount, it will fall under the typification of article 48” of the law, which is none other than the one referred to trafficking, with a prison sentence of 10 to 25 years.
Far from being merely nominal, this jurisdictional scheme against drug production, sale, and consumption has a concrete correlation. In its 2016 report “Prisoners without a sentence. Current situation of pretrial detainees in Bolivian prisons,” the Ombudsman’s Office indicates that in the country’s 14 prisons, there were 13,940 inmates, with the third most common reason for their incarceration being crimes against Law 1008.
Those imprisoned for violating this law represent 8% of the total, only surpassed by those accused of rape (16%) and aggravated robbery (14%), and above those charged with robbery (7%), murder (6%), and fraud (4%).
As if that were not enough, of the universe of inmates, 9% are women, a percentage 50% higher than in the region, “demonstrating that criminalization is highly selective and discriminatory since women, especially the poorest, are exploited in drug trafficking and transport and are harshly punished. Moreover, in its analysis of prison overcrowding, which in Bolivia exceeds 300%, the Ombudsman’s Office states that among the three main causes of overcrowding are “punitive criminal justice policies (criminalization of micro-trafficking in Law 1008)”. In this light, the risk of going to jail is not only real but also very high regarding crimes against anti-drug laws.
Pablo and Hortensia Are Not Criminals
Neither Pablo nor Hortensia are criminals, although police and judicial operators might say otherwise. He is a young man suffering from a chronic illness, which in his childhood was West Syndrome, and today has mutated into Lennox-Gastaut Syndrome (another form of epilepsy). She is his mother and wants him alive and well.
That is why, about eight years ago, when his brother was living in Colombia, she got him to send her some bottles of cannabis oil which, with the approval of Pablo’s neuro pediatrician and the collaboration of local health authorities, reached Cochabamba (central Bolivia), was dosed to the then child and reduced his daily seizures from 15 to 2.
The product, legal for use in Colombian territory, only lasted about three months in Hortensia’s house, but those months were extraordinary. The epileptic seizures were drastically reduced, and the few Pablo suffered were mild and with less risk of physical harm.
The mother had the chance to devote herself to her other two children, who are now 13 and 9 years old. She could watch her firstborn walk without worrying that he would convulse and collapse at any moment. She lived without fear, or at least with less anxiety. But, it was over. His brother could no longer send him the oil from Colombia, and in Bolivia, it is only sold clandestinely and illegally, without health guarantees or quality control.
Fear has returned to her home. “I see him walking, and I am automatically behind him. If he is standing, I am already running because we don’t know, at any moment he could have (an attack),” she says, as she hands her son pieces of a “Chavo del 8” puzzle, his favorite game and his favorite character, respectively.
High Cost of Legal Treatments
With the fear, economic hardship has also returned. Covering Pablo’s traditional medications demand very high costs. Every day he must ingest three units of lamotrigine (200 milligrams per dose) and two units of levetiracetam (1,000 milligrams per dose). Both are medications for convulsions, for which they spend 150 bolivianos (22 dollars).
Their health insurance covers some prescriptions, but not all. As a result of the coronavirus pandemic, since 2021, it no longer provides them with levetiracetam, so they must get it on their own. “Sometimes, the doctor himself gives me samples, or I have friends too, and I have to go ask for samples to give me. Or in the end, we buy it,” she says, keeping an eye on her son, who has gotten up from the couch to go get some water crackers, which he likes as much as “Chavo del 8.”
The Covid-19 health crisis has made care for illnesses like Pablo’s less of a priority. The difficulty in accessing expensive medication has been added to the closure of the special education center where his parents used to take him. He is now in the exclusive care of his mother during the day and his father at night. He is the only one who works and generates resources to support his family of five, as Hortensia must devote herself full time to caring for her sick son.
“I am very stressed, maybe because of being behind him, not taking care of my other children, or the house or myself… So, it’s all about him,” she admits with regret. But, before falling apart, she believes it is important to make herself heard, to ask the Bolivian authorities to facilitate the legalization of cannabis for medicinal use: “I would ask for legalization to make this type of medicine (oil) because I have seen that (Pablo) has improved.
And just as her eldest son’s health improved for a few months, so did the quality of life of her and the rest of her family. “Our quality of life during that time has been good. That is why I ask you to please help us in this way, with medical cannabis”.
Bolivian Crime and Sin
There was a time when Teresa was a “superwoman.” Perhaps, a sort of female version of Bruce Willis’ character in the film saga “Unbreakable” (M. Night Shyamalan): nothing could hurt her or, at least, that’s how she felt. Despite having been diagnosed a decade ago with fibromyalgia, five years later, she had found the potion to make herself unbreakable: cannabis oil.
It was not a short or easy road. With a strict Christian upbringing, she frowned upon the possibility of medicating herself with derivatives of a plant that, especially in Bolivia, has such bad press and is often reduced to an illegal drug. A boyfriend of hers who used it encouraged her to try it, and, to her surprise, she discovered that the substance neutralized the most aggressive symptoms of the syndrome she suffers: muscular pains throughout the body, excessive tiredness, memory loss, depression, cardiac arrhythmia, and irritable bowel.
“Cannabis oil has been a blessing in my life because it has made it possible for me to be more me, to be a normal person, to be able to do my job, to be a mom too,” says Teresa (who is also not named Teresa), a single mother of two daughters, with university studies and self-taught in the preparation of medical cannabis for self-consumption. She, who looks more than 30 years old, shares her personal details cautiously, in dribs and drabs, almost in the way she learned to give herself cannabis oil.
Like Hortensia, Teresa lives in fear. Fear of the law, which could prosecute and punish her, but also of her social environment. Her family never accepted that she had to “get high” to ease her physical and emotional pain. Making and taking cannabis oil was seen as both a crime and a sin against the family’s Christian morals.
Prejudice Prevents Bolivia From Legalizing Cannabis
Prejudice is another obstacle to the regulation of medical cannabis in Bolivia. Consumers, but also activists, agree. Gabriela Monasterios of the Proganja collective assures that in the country, “we lack too much knowledge.” This explains why she has studied on her own outside Bolivia in disciplines such as medical cannabis, cannabis baking, and cannabis journalism. Together with other activists, she founded Proganja, a collective that brings together doctors, growers, lawyers, and other supporters.
From that experience, she confirms that home-growing medical cannabis in Bolivia is already practiced as a clandestine activity, like all those involving this substance. Although it is not possible to make a census of the number of growers and consumers in the country because it is an illegal area, she knows more and more people who, like Teresa, have learned to make oil or other products according to their health conditions. “If in other countries they rely on self-cultivation, it is because everyone knows what they are growing and what final product it will lead to, because, in the end, it is a medicine,” she explains. The multiplication of local producers is also due to the fact that “the (cannabis) medicine brought from other places is too expensive and difficult to access.
However, the manufacture of oil or other products is not something that can just be done. Teresa recalls that she started out buying oils of different origins and qualities. It didn’t go so well because, as she would later notice, some “were quite stretched” (mixed, not pure) and didn’t generate the desired effects for her. “It’s difficult to find the exact dose for the type of ailment you have because they are different doses,” he says, in tune with what Gabriela said. “I started researching and learned what to do.” That routine made her dependent on suppliers of the raw material from which the oil is extracted. And because of the illegality of the circuit, there were many who disappeared from one day to the next. “Even in my desperation to be able to be well, because I really saw that I was well and healthy, I had to go to more dangerous places and try to access the raw material,” she says.
However, Teresa’s exceptional period as a “superwoman” ended when family pressures came, accompanied by legal threats. Her family forced her to stop making and taking cannabis oil, warning her that if she did not agree, they would resort to the law to denounce her and take away the guardianship of her two daughters. The woman had to choose between her health and her daughters. And she chose her daughters. She returned to traditional medication, which is more expensive (60 to 70 bolivianos per day, equivalent to 10 dollars) and harmful to her body (she has already lost her gall bladder due to excessive medication).
Prohibitionist Logic Prevails in Bolivia
Teresa’s situation is a consequence of what lawyer and activist Gloria Achá calls “prohibitionist logic.” This logic which prevails in Bolivia, prevents a serious debate on regulating cannabis and other drugs and leads to “obscurantism” without accurate information or “scientific evidence” to guide the discussion. “Drug issues are approached from prejudice, from conservatism, and falsehood. Very little is said with evidence. What is said is more based on stereotypes,” says this woman who belongs to the organization Acción Andina and has been involved in one of the few milestones in the fight against the decriminalization of medical cannabis in this country.
A Bolivian Decriminalization Milestone
In November 2021, the State Agency of Medicines (Agemed), under the Ministry of Health, authorized the “exceptional” use of medical cannabis to reduce spasms and improve the quality of life of Celeste, a five-year-old girl with cerebral palsy. As coordinator of Acción Andina, Achá led the legal proceedings to obtain the state authority that would allow Celeste’s family to import cannabis oil, thanks to the endorsement of a prescription issued by the Chilean doctor Pedro Musalem, a specialist in Public Health.
Obtaining the authorization, which had the support of the Bolivian Ombudsman’s Office, was celebrated as a historic achievement for the community of activists, patients, and families of chronically ill patients. However, it was a half-hearted, truncated achievement. From November to date, Celeste’s family has not been able to import the oil due to a lack of money to travel and buy the product. Agemed has not processed similar requests, and the public debate has become politicized in the worst sense.
When asked for this report, the director of Agemed, Yuri Quisbert, confirms that they granted Celeste’s request “exceptionally,” so “there has not been any other after that”. And even without saying so explicitly, the official implies that issuing another authorization would be something very complicated, something exceptional only for cases of life or death: “Last year’s disposition was very rigorous, in reality, because we were talking about the life of a patient, it is not just like that.”
On the political side, the most recent calls to decriminalize cannabis for medicinal use have come from figures opposed to the governing party (MAS). In December 2021, Iván Arias, the current mayor of La Paz and former minister in the transitional government of Jeanine Áñez, declared that he would push for debate on the issue. In mid-July 2022, Senator Andrea Barrientos, of the main opposition force in the Legislative Assembly (CC), declared herself in favor of “legalizing medical cannabis.”
Their statements were widely discredited by sectors related to the “masismo”, including the pro-government newspaper Ahora el Pueblo. A curious reaction, to say the least, if one considers that the MAS brought to the presidency of Bolivia the main leader of the coca growers of the Tropic of Cochabamba, Evo Morales, carrying as one of his main political banners the denunciation of the criminalization of the coca leaf as cocaine and the ignorance of its ancestral and medicinal properties, a situation similar to that of cannabis.
The Medical Cannabis Debate
These controversies reflect the highly non-technical debate around regulating medical cannabis in Bolivia. Hence, activist groups are immersed in political lobbying to combat the prohibitionist stigma and politicized debate. This is the case of the Papá Ganjah collective, whose action plan “Route of access to cannabis” deploys “indoor” activities (informative and educational talks with experts) and “outdoor” activities. The latter aims to convince local and national authorities of the need to advance in regulating cannabis for medicinal purposes.
Alezo Bellota, a collective member, reports that they have already held meetings with representatives of the Mayor’s Office of La Paz and the Vice-Ministry of Social Defense and Controlled Substances (part of the national government). The former have been more open to their proposals, while the latter have perceived more hostility and even intimidation, to the point that on one occasion they were visited by police officers to learn about the nature of their activities. “In our first meeting with the Vice-Ministry’s Prevention Unit, they scared us by telling us that we were working on an illegal issue, so we had to be very careful, and I took that as a threat,” acknowledges Bellota. “However, we are not doing anything out of context, outside the legal framework; we are focused on trying to change drug policy in Bolivia.”
Work like that of Papá Ganjah, Acción Andina, or Proganja, among other civic organizations, is valuable on the road to changing Bolivian anti-drug policy. However, they are still insufficient. Gloria Achá believes that, apart from the efforts in favor of regulation of medical cannabis, there is a need for greater articulation in civil society, “as there was at the time when the DEA was in Bolivia when there was a “war on drugs” and foundations and NGOs were fighting for those affected.” To this lack of social articulation, she attributes the persistence of prejudices and the absence of “critical thinking” when judging the medical use of cannabis.
Teresa is one of these victims of the uncritical and prejudiced view of drugs, particularly cannabis. Her family pushed her to stop a treatment that, besides being good for her, cost her less: 100 bolivianos ($15) compared to 2,100 ($304) a month. The medications she now takes (gabapentin and amitriptyline) do not give her complete relief. They leave her semi-drowsy, in a bad mood, and, on occasion, lead her to be hospitalized. Worse, they come with additional expenses of up to 2,700 bolivianos (US$390) a day.
“With the oil, I have never been hospitalized. I have never relapsed in the lows of my illness. But, unfortunately, I cannot fully comply with my legal treatment,” she laments, alluding to the expense of fibromyalgia, a disease that, according to the Spanish Rheumatology Foundation, affects 2 to 6% of the population, the majority of which are women. But, even more than the money, it hurts her that she no longer feels fulfilled as a woman and mother. “At one time, I was the superwoman, and because of the disease, I could no longer be that; I still can’t.”
Black Market, Illegal Marijuana
Elena had been dealing with insomnia for months when she ended up in the emergency room of a clinic in La Paz, where she lives and works. Only then, with medication, was she able to fall asleep for a few hours. It was a turning point. Soon after, she left her prejudices behind and listened to her doctor brother, who had recommended that she look for cannabis oil. But, after all, it would not be for her but Eduardo, her four-and-a-half-year-old son, diagnosed as a baby with moderate autism.
At 39, she had divorced shortly before, so the decision was all hers. Her job, linked to the health sector, allowed her to find a product seller in a central square. She bought it at a high price, 420 Bolivianos (US$60), and when she gave it to her son to take, she regretted it. “It smelled powerful of cannabis, and I couldn’t stand my Eduardito tasting and smell like that,” she recalls.
To make matters worse, the substance, which looked homemade, dark, and thick, had no effect on the child: he barely spoke, kept on his cell phone and TV, and played alone (despite having a younger brother of two and a half years) and, above all, could not sleep. Instead, it was the son’s chronic insomnia that had triggered the mother, who had to spend her nights trying to calm him down and not infrequently suffering his blows of despair. Finally, when the crises became unbearable, she resorted to clonazepam and some antipsychotics to make Eduardo rest. However, these medicines caused “my son to walk around like a fool.” And he didn’t like that.
Things changed when she asked a neurologist, an acquaintance of hers and very respected in the Bolivian environment, if he believed that cannabis oil would be suitable for her autistic child. The doctor replied that he was waiting for her to take initiative, offering to get the product and guide her on dosage. He sold her a bottle of Colombian origin for 300 Bolivianos (US$43) and recommended that, taking into account the weight of a four-and-a-half-year-old patient, she should give him a maximum of 10 drops a day.
The oil gave the mother more confidence, with a thinner consistency, lighter color, and menthol fragrance. First, she gave it to him at various times of the day and, as it didn’t work well, she adjusted the schedule, had him take it all at night, and that’s when the improvements came. In the five months, he has been taking it, Eduardo has been able to pronounce the letters of the alphabet, count on his fingers and, most importantly, sleep through the night. And if he sleeps, so does his mom.
The Clandestine Cannabis System in Bolivia
The story of Elena and Eduardo (other fictitious names) sheds light on the various clandestine markets through which medical cannabis circulates in Bolivia. One is the one that, through references from acquaintances, is accessed under similar modalities to those governing the trafficking of other controlled substances: the personalized sale of products of dubious quality. Another is the one that already has the intervention of professionals -especially doctors- specialized in obtaining more certified products and guiding patients in their use.
More recent examples that are in significant expansion at this time are the so-called “smuggling fairs” in the capital cities like Cochabamba and La Paz. These Fairs offer different articles of domestic consumption (from food to cleaning products), entered into the country illegally, without going through customs, and sold directly to the consumer in improvised markets in public roads. In Cochabamba alone, this report identified three of these smuggling fairs. The supply is cheap, much cheaper than in the formal markets, but does not offer any guarantee of quality. This is the case with cannabis oils, which may be adulterated, if not other substances.
On the other hand, the circuits mediated by health professionals promise higher health quality and advice on use. But, of course, the doctors who prescribe, manage and sell the oils only do so underground, owing to the legal consequences of doing so openly.
It is no coincidence that the only authorized prescription in Bolivia, that of the girl Celeste was issued by a Chilean doctor, Pedro Musalem. In contact with this research team, the specialist says that he has been working for eight years with the supply of medical cannabis to patients in his country and others. In Bolivia, he is currently accompanying two after Celeste. And if he adds them all up, he estimates that he has advised about 10 Bolivians, half of them children with epilepsy, autism, or cerebral palsy, and the other half adults with cancer and Parkinson’s disease.
Doctors Recognize the Medical Benefits of Medical Cannabis
Based on the available scientific evidence and his personal experience, Musalem specifies that cannabis has an anti-inflammatory potential against pathologies such as autoimmune diseases, rheumatoid arthritis, intestinal inflammation, or Crohn’s disease. It also acts favorably, he adds, in chronic diseases of the central nervous system: Parkinson’s, epilepsy, amyotrophic lateral sclerosis, or cancer. “Cannabis produces hunger, sleep, and relaxation. And that is exactly what a person with cancer usually needs,” he explains.
Strictly speaking, it is the cannabinoids that have this and other therapeutic effects. Of the more than 70 that the plant has, the two main ones are Tetrahydrocannabinol (THC) and Cannabidiol (CBD). Both have different but complementary functions. While THC, the psychoactive component, usually causes relaxation and drowsiness, CBD has anticonvulsant and anti-inflammatory effects. The treatment’s success depends on the combination of both, which varies by disease and patient.
These medicinal properties were recognized in cannabis by the UN in December 2020 in time to remove the plant from the most dangerous narcotic drugs classification. And those are the medicinal properties that the Bolivian state is still reluctant to recognize operationally, despite the fact that since 2017 it has a law, 913 on the fight against the Illicit Trafficking of Controlled Substances, designed to displace 1008 and which, in articles 16, 18, 18, 19 and 20, opens the possibility of handling, importing, producing, researching and marketing controlled substances such as cannabis, provided that there is prior registration and control and a medicinal-scientific purpose is pursued.
The Ombudsman, Nadia Cruz, refers to this norm in her eagerness to clear the way toward regulating medical cannabis. Her objective is to “eliminate cannabis from list 1 of Annex 1 of Law 913. Doing so would ensure that it is not considered a dangerous chemical substance for human consumption, and rather, support can be given so that the state can generate medicine companies that specialize in cannabis.”
But, even before that, Cruz considers it urgent to institutionalize a regulation procedure for the importation of the medicinal product “because in Bolivia we do not have state or private production companies, so we could not yet talk about production and commercialization.”
The Future of the Bolivian Cannabis Market
Initiatives such as this one seem relevant to respond to the medical cannabis market in Bolivia, which, although clandestine, unregulated, and illegal, continues to grow.
This fact was revealed in an exploratory study by the Jampi Q’umir collective, carried out in 2020, based on a survey of 63 people. At that time, it was established that, of the total number of queries registered, 54% corresponded to women and 46% to men. The inquiries came from the nine departments of the country and even from other countries, says Jorge (who prefers not to be identified by his last name), from Jampi Q’umir.
As for what they sought, 34% were looking for oil, 19% for information, 9.5% sought ointments, and some wanted to start a cannabis enterprise. When asked about the product recipients, 23% did so for their parents and 20% for their children, siblings, and spouses.
Even with this evidence, the Bolivian state’s repressive bodies avoid discussing any policy of tolerance toward medical cannabis markets. The sub-director general of the Special Forces against Drug Trafficking (FELCN), José Luis Assaf, asserts that dealers use the definition of medical cannabis oil to offer and sell derivatives extracted from cannabis. “And in our environment, it is restricted, within the controlled substances and is subject to seizure. Anything with a controlled substance is subject to investigation by the police,” he tells this investigation team.
While these contradictions are still being resolved in Bolivian institutions, which approve laws favorable to medicinal use while warning of punishing sellers, Bolivians do not give up curing themselves with cannabis from clandestine markets.
Some people, like Hortensia, ask the authorities for access to products to cure their children’s ailments and obtain a better quality of life. There are also those who, like Teresa, are waiting for state regulation to combat the social prejudices that stigmatize and prevent the use of medicines that are beneficial to patients’ health. And there are also those like Elena, who rely on doctors to obtain substances that, while illegal, have a positive impact on the condition of their loved ones.
After all, Hortensia will do everything possible so that Pablo does not get any more head wounds. Teresa hopes to become a “superwoman” again. And Elena wants no more insomnia. This shared will is stronger than all the restrictions, pressures, and threats that the Bolivian state and the most conservative social classes exert against them and their families.
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