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[MANILA] She is just seven years old, but in her short life Julia Cunanan has already been prescribed seven anti-seizure drugs, including phenobarbital and Valproic acid.
 
While her medication has since been trimmed to two, the child, who suffers from an intractable form of epilepsy called Dravet syndrome, still experiences the side-effects of these synthetic drugs which include damage to the kidney, liver and pancreas.

“The real objective is not legalisation because marijuana is already legally recognised as [a] medicine under existing Philippine laws”

Chuck Manansala, Filipino Medical Cannabis Research Center

“There was a time that my daughter was hospitalised because her pancreas was bleeding because of the side-effects of these synthetic drugs,” says Donnabel Cunanan, Julia’s mother and a dentist by profession.
 
“The seizures are still there, the damage and the pain are really harmful,” she adds, explaining that her daughter may have up to 1,000 seizures daily. She said she also noticed developmental delays in Julia, which she attributes to her medications.
 
Cunanan is the spokesperson and one of the founding members of the Philippine Cannabis Compassion Society, an advocacy group lobbying for the legalisation of medical marijuana in the Philippines, a country that has been put under the limelight since 2016 because of President Rodrigo Duterte’s controversial war on drugs.
 
Life imprisonment
 
Despite local and international criticism against the drug war, Duterte recently stated that he will intensify anti-drug operations. The Philippines continues to implement the Comprehensive Dangerous Drugs Act of 2002, which means that anyone caught with 500 grams or more of marijuana or 10 grams or more of marijuana resin or marijuana resin oil is punishable with up to life imprisonment and a penalty of up to close to US$200,000.
 
However, the war on drugs comes amid a growing openness of using cannabis for medical purposes.
 
In January 2019, the World Health Organization (WHO) made headlines when it recommended to the United Nations the reclassification of cannabis and cannabis-related substances following the report of the 41st Expert Committee on Drug Dependence in June 2018.
 
In a letter to UN secretary-general António Guterres, WHO director-general Tedros Adhanom Ghebreyesus said cannabis and cannabis resin should be struck out from Schedule IV – the most restrictive category of the Single Convention on Narcotic Drugs (1961) – and instead be categorised exclusively under Schedule I, which recognises that the substance, while having known negative effects, can also be used for medicinal purposes.

medical marijuana infographic
 
“[The] WHO recommendation is meant to allow better access to cannabis-related pharmaceutical preparations and [to encourage] that more scientific research is carried out on these substances and more countries use evidence-based approaches in using them for medical purposes,” explains Gilles Forte, coordinator at the office of the assistant director-general of WHO’s Access to Medicines, Vaccines, and Pharmaceuticals.
 
Currently, morphine, cocaine and opium are all classified under Schedule I. Heroin, meanwhile, is categorised both under Schedules I and IV, similar to the current classification of cannabis and cannabis resin. 
 
“At the time of the establishment of the 1961 convention, cannabis was not recognised to have any therapeutic use,” says Jason White, emeritus professor of the school of pharmacy and medical sciences at the University of South Australia and chair of the WHO Expert Committee on Drug Dependence. “We now recognise therapeutic uses for cannabis – understood in the Conventions to include medicines prepared [with] cannabis – based on extensive research.”
 
This move by the WHO is a reflection of the changing stance of the international community regarding medical marijuana. While Canada, Uruguay and the US states of Alaska, California, Colorado, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont and Washington have already legalised the use of marijuana for recreational purposes, many countries have also changed their policies with regards to medical cannabis.
 
In South-East Asia, Thailand made history as the first country in the region to allow the use of medical marijuana in December 2018, an act that was described as “a New Year’s gift from the national legislative assembly to the government and the Thai people” by Somchai Sawangkarn, the legislator who led the drafting committee. The law not only covers the use of medical marijuana but also the in-country production and cultivation of the plant. Earlier, South Korea became the first East Asian country to legalise medical cannabis on a case-by-case basis.

Even Singapore, which imposes the death penalty for drug possession, is now exploring ways in which cannabinoids – albeit in their synthetic form – can be used for medical purposes. In a statement to SciDev.Net, the National Research Foundation said: “The synthetic cannabinoid biology programme … will develop proprietary national strains as hosts for producing the medicinal cannabinoids.”
 
The war on drugs
 
The Philippines is not the only country in South-East Asia that continues to enforce strict policies on medical marijuana. Countries such as China and Indonesia impose the death penalty for drug possession.
 
Those who were caught with drugs in the Philippines were also put on death row up until 2006, when the death penalty was abolished. Even without that in place, those possessing cannabis, regardless of whether for medical or recreational purposes, can still be locked up in jail or killed because of the drug war.
 
While there were attempts made by SciDev.Net to reach out to the Philippine Drug Enforcement Agency, the lead government agency responsible for the apprehension of violators of the drug policies, inquiries and interview requests to get data on the number of people arrested or killed for possession of marijuana went unanswered.
 
There are inconsistencies in the numbers reported by both government and non-government agencies in terms of the number of people to have been killed for drug possession. The Department of Health (DOH) also could not provide the number of inpatient clients currently in their facilities for marijuana use. Ivanhoe Escartin, DOH’s programme manager of the Dangerous Drugs Abuse Prevention and Treatment Programme, explains to SciDev.Net that this was because their patients tended not to use just one drug but a combination of them.
 
It is in this context that the Philippine Cannabis Compassion Society, which was founded in 2014, is driving its advocacy. “It was one of the most difficult decisions that we had to make in our lives,” says Cunanan.
 
Their efforts were not without fruit. Their lobbying led to the filing of a bill in support of medical marijuana, although this resulted in a statement from the Philippine Medical Association against this. In December 2018, the group felt a flash of hope when Malacañang Palace – the seat of power in the Philippines – issued a statement that Duterte will sign “any bill” to legalise its use, thanks in part to the publicity the issue gained when Catriona Grey, the Filipino winner of the 2018 Miss Universe pageant, expressed her support. Duterte, has since retracted his statement of support, uttering “not in my time” regarding to the passing of the bill.
 
Cunanan, however, remains optimistic. “You know President Duterte. That’s his character. He would say things, and then after a few months, he would retract, but we’re still hopeful,” she says. She adds that the Philippine Cannabis Compassion Society sees the recently concluded Philippine mid-term elections as an opportunity to have the bill reconsidered. “We hope and pray that the promises that [the legislators] made would translate into action.”
 
The question, however, is if there is a need for a new policy in the first place. Some government officials, including Senate president Vicente Sotto III, released statements that there is no need for the law. Benjamin Reyes, undersecretary of the dangerous drugs board, concurs, saying in an interview with SciDev.Net, “Under the FDA (Food and Drug Administration), as well as the Republic Act 9165 (Dangerous Drugs Act of 2002), it allows the use of dangerous substances for medical purposes as long as you follow the process.” 
 
Chuck Manansala, the president of the Filipino Medical Cannabis Research Center, agrees with the position that legalisation is not an issue. “The real objective is not legalisation because marijuana is already legally recognised as [a] medicine under existing Philippine laws,” he tells SciDev.Net. The objective, he says, is to produce medicine from locally cultivated or imported cannabis, register it with the FDA, and make it affordable, accessible, and available to patients.
 
Priced out
 
These are also the reasons why the Philippine Cannabis Compassion Society continues to lobby for the passing of the medical marijuana bill.
 
“It’s not compassionate at all,” says Cunanan on the “compassionate use” scheme indicated in the DOH administrative order that allows patients to access controlled substances for medical purposes.
 
She explains that under this current setup, only the medications that have been approved by the Philippine FDA can be accessed. For epilepsy patients, that means that only Epidiolex (cannabidiol), the first marijuana-based drug approved by the United States FDA, is available to them. However, Cunanan says that buying this medication means spending about US$30,000 per year, which many patients in the Philippines cannot afford.
 
“How can it be compassionate when even I myself, a practicing dentist, [consider this] as very, very expensive? How much more for the ordinary Filipino citizens?” As of 2015, the average family income in the Philippines is US$5,077 per year.
 
 

Donnabel Cunanan's message to the newly elected legislators in the Philippines to support medical marijuana

The process of getting a permit under the compassionate use scheme is complicated. Prescriptions of medical marijuana are limited to physicians who have been issued an S2 license by the Philippine Drug Enforcement Agency and who are issued special prescription pads by the Department of Health. They are responsible for submitting the prescription to the Philippine FDA, which reviews the qualifications of the physician and the legitimacy of the prescription. Once these are reviewed and approved, the permit is issued.
 
Reyes admits there is an issue with access, although he says that they are now taking steps to remedy this. “Right now, we are in the process of reviewing the guidelines [for compassionate use] because they’re from way back in 1992, so they’re obsolete,” he says, referring to the health department administrative order. Reyes says they are aiming to release the amendments before the end of the second quarter of 2019.
 
Currently, there are no local or imported marijuana-based medicines available in the Philippines, so patients need to import to get their prescription filled. This can entail costs – from the price of the medicines to the shipping fees – that they can ill-afford. Furthermore, medications cannot be brought into the country easily. These have to be registered with the Philippine FDA. In-country production is still a long way away. This presents a glaring gap that medical marijuana advocates have quickly spotted.
 
Lawbreakers
 
“No Filipino has accessed medical cannabinoids legally, except those who flew abroad. Patients here are forced to break the law to acquire it,” says Gem Mutia, founder of the Philippine Doctors for Medical Cannabis.
 
But Reyes stands by the position of the government. “We in government understand the demand, but we need to be careful in assessing these types of medicines.” From the position of the Dangerous Drugs Board, this means ensuring that medical marijuana is available as a finished product to regulate the dosage. He says that the raw form of marijuana is not recommended because of the uncertainty of the chemical properties of the cannabis that will be used.
 
This reason, however, is also precisely why medical marijuana law should be passed, argues Cunanan. “The more we allow them to get it illegally, the more we put them at risk.” This is not just to protect them from seeing jail time but also to protect patients from adverse effects.
 
Fake news
 
Medical marijuana’s status as a taboo topic has forced many people to turn to questionable sources of information.
 
Reyes says that social media – which was the platform that led to advocacy groups such as the  Philippine Cannabis Compassion Society – is instrumental in spreading “fake news” about medical marijuana. He expresses his frustration that unproven information that marijuana is a “wonder drug” that can cure just about anything, from toothaches to cancer, is now making rounds online.
 
As an example, he cites Epidiolex. He says that there are now claims that this medication can treat all forms of epilepsy, when in fact, it is intended for the treatment of seizures associated with Dravet Syndrome and Lennox-Gastaut Syndrome.  
 
Word of mouth has also helped in spreading anecdotal – but untested – information about medical marijuana. A Philippines-based interviewee who refused to be named said that she smokes fully cured cannabis buds to help her in managing her alopecia.
 
According to her, she tried different medicines by dermatologists, but her condition only seemed to worsen. Her cousin, who smokes marijuana for recreational purposes, suggested that she try smoking it for her condition. She discovered that smoking marijuana helped her manage her stress and allowed her to sleep for more than nine hours a day. Lack of sleep and stress are associated with hair loss. “Marijuana is medicine and is so effective because it is organic and natural. For me, it can cure anything.” She says she grows her own marijuana, although she takes certain steps to protect herself because of the war on drugs. Social media, as well as anecdotal evidence, are some of the concerns that the Philippines’ Dangerous Drugs Board finds itself grappling with. “The problem with these statements is that they may mislead some individuals. While we’re saying yes, we will see marijuana-based medicine products in the near future, the many claims present a danger,” Reyes said, adding that these claims can encourage people to use marijuana for recreational purposes.  
 
“Proper patient education is key to avoid adverse effects,” says Mutia.
 
Regardless of the position in this debate, both sides understand that the wellbeing of patients takes precedence. For Cunanan, this means appealing to the government to recognise the needs of the patients, including her own daughter. “Our message for them is to be able to help us and see the patients not as drug addicts but as patients,” she says.
 
This piece was produced by SciDev.Net’s Asia & Pacific desk.