I, Dr. Milton N. Estes, declare as follows:

1. I am a physician licensed to practice in the State of California. I received both my undergraduate and medical degrees from the University of Chicago and completed my post-graduate medical training at St. Luke's Hospital, San Francisco. I am board certified by the American Board of Family Practice, and licensed to practice in the State of California. I am a member of the American Academy of Family Physicians, the California Academy of Family Physicians, the California Medical Association, and the Marin Medical Society.
2. From 1971 through 1974, I was Medical Director of the Orange Cove Family Health Center, a federally funded health clinic serving rural farm workers. Since 1974, I have maintained a private family practice in Mill Valley, California. In recent years, I have become the largest private provider of HIV care in Marin County. Since 1995, I have been Medical Director and Senior Physician for the Forensic AIDS Project. The Forensic AIDS Project, operated by the Department of Public Health of the City and County of San Francisco, provides early intervention, education, and medical care for inmates who are HIV-positive or who have AIDS.
3. I am presently an Attending Physician with active duties at Marin General Hospital. My previous hospital experience includes being Chair of the Department of Family Practice at Marin General Hospital, and Attending Physician at both Ross General and Mt. Zion Hospitals, and the California Pacific Medical Center (San Francisco).
4. My academic appointments include Clinical Instructor in Family Practice and Assistant Clinical Professor of Family Medicine at the University of California-Davis (1972-84), and Associate Clinical Professor in the Department of Obstetrics, Gynecology & Reproductive Medicine at the University of California-San Francisco (1983-present).
5. I serve on several professional and community boards, include many years as a member of the Oncology Committee (1990-present), Bioethics Committee (1993-present), and AIDS Task Force (1986-present) at Marin General Hospital, as well as the Medical Advisory Board of the Coalition for the Medical Rights of Women (1984-1987). I currently serve as both the chair of Marin General Hospital's AIDS Task Force and the Marin Medical Society's AIDS Committee. I have been a member of the Marin AIDS Advisory Commission since its inception in 1987. For the past twenty years, I have lectured widely on issues of medical ethics, HIV and AIDS. In 1989, I was named Physician of the Year by the Marin Medical Society. In 1990, I received the Benjamin Dreyfus Award from the Marin Chapter of the American Civil Liberties Union; and in 1992, I received the Martin Luther King Humanitarian Award by the Marin County Human Rights Commission.
6. Last month, one of the most prestigious medical journals in the world, The New England Journal of Medicine, published an editorial that confirmed what practicing clinicians have long known: that relatively small amounts of marijuana can provide striking relief from intractable nausea, vomiting, pain, and anorexia that frequently plague persons suffering from cancer, AIDS, and other serious illnesses.
7. Shortly before that editorial, the nation's top law enforcement officials, joined remarkably by the Secretary of Health and Human Services, announced before cameras that they would bring the full force of government authority to bear on physicians who in their best medical judgment recommend medical marijuana to their seriously ill patients.
8. As a result of the government's public threats, I do not feel comfortable even discussing the subject of medical marijuana with my patients. I feel vulnerable to federal sanctions that could strip me of my license to prescribe the treatments my patients depend upon, or even land me behind bars. I am worried that a government agent, posing as a patient, will try to infiltrate my office in order to provoke a statement that the federal government considers dangerous but which I, as well as thousands of my colleagues, the New England Journal of Medicine and the voters of California, regard as sound medicine. As a result, I am somewhat less trusting of new patients. I am also concerned that a former patient who may himself feel vulnerable, or one who suffers an emotional disturbance (perhaps caused by the stress, anguish or dementia of late-stage AIDS) might make out- of-context reports to federal authorities that dovetail with the government's official policy regarding medical marijuana. Because of these fears, the discourse about medical marijuana has all but ceased at my medical office. If perchance the issue of medical marijuana does arise, I make no notes of the substance of the conversation for fear of government reprisal. My patients bear the brunt of this loss in communication.
9. Restrictions on the flow of relevant information between doctor and patient are, by definition, counter- therapeutic. It is critical for physicians to know what their seriously ill patients ingest. But this knowledge is generally provided by the patients themselves. That will occur only if patients trust their physician to maintain professional confidences and to use that information not to judge, but to treat. The dialogue that ensues from this atmosphere of trust continues throughout the course of treatment. I do not treat the patient as an anonymous subject; rather, the patient and I work together. We discuss together the symptoms and possible treatments. It is a critical collaborative effort.
10. Physician-colleagues work collaboratively as well. As doctors, we share and assess our observations, experiences, ideas, and knowledge. Government threats inhibit the discourse among physicians which is critical to advance our understanding of disease and the efficacy of certain treatments. Physicians are naturally reluctant to discuss any subject which implies or is associated with potentially illegal practices. Thus, the current threats stifle the free flow of ideas that medicine has traditionally depended upon to improve health care.
11. My fear of discussing medical marijuana precludes the climate of trust that must be established between doctor and patient. Imposed silence on any relevant issue, including the use of marijuana, leaves both patient and doctor with unspoken (and thus unanswered) questions: "What else is not being disclosed or addressed?" "Are we overlooking information which could be critical to medical treatment?"
12. I care for an increasing number of patients with HIV in various stages of illness. Over the years, through cautious trial and error, close observation, ongoing consultation and persistent research, AIDS researchers and front-line physicians (like myself) have developed an increasingly effective arsenal of drugs and protocols to combat HIV and AIDS. Only a few years ago, a positive test for HIV was perceived as the first step toward inevitable death. Today, our years of research have resulted in significant advances in drug therapies; there appear to be treatments which have brought us, as healers and as a community, within sight of the day when we eliminate the HIV virus and thus substantially improve the quality of life and extend the lives of persons inflicted with this epidemic.
13. However, the treatments of today, like those of previous years, are not without unknown or unintended effects. Some of my patients routinely take almost a dozen different medications each day to combat the virus and the opportunistic infections which prey on the body's compromised immune system. This daily regimen of medication poses serious problems for a significant number of my seriously ill patients. First, by definition, these pills must be swallowed. One of the frequent symptoms of HIV-related illness is severe and chronic nausea, such that swallowing pills on a regular basis can be difficult, if not impossible. To make matters worse, nausea is a common side effect of the medications themselves. Thus, a debilitating and demoralizing cycle sets in: the patient must repeatedly swallow pills which induce nausea, which is addressed, in turn, by yet another round of pills.
14. The inability to swallow can have devastating consequences for both treatment compliance and the patient's general health. Not only must patients be able to ingest medications, they must be able to eat and hold down food in order to obtain the nutrition essential to anyone's health. The need for regular and adequate nutrition is even more critical in patients whose compromised immune systems render them vulnerable, especially when accompanied by late-stage wasting syndrome. Moreover, some of the medications prescribed for HIV/AIDS patients must be taken on a full stomach to allow full absorption and maximum efficacy. Thus, a premium is placed on the patient's ability to swallow both medications and food. Chronic and severe nausea and loss of appetite caused by the illness and/or clinical therapies pose severe obstacles to a patient's well-being.
15. In my experience as an HIV/AIDS physician, a significant number of patients use marijuana as both an anti- emetic (anti-nauseant) or appetite stimulant. For persistent nausea, I often prescribe Compazine or Marinol, a synthetic form of THC (the active compound found in marijuana), both of which are FDA-approved. But some patients do not tolerate these medications well. Many have complained of feeling dysphoric using Marinol or find the duration of effect unduly long. These adverse effects are of concern to me, not only because of the immediate effects on patient comfort and functioning, but also because they may signal greater difficulties in patients' inability to comply with medical protocols, now and in the future. Especially with the new generation of AIDS drugs, strict compliance with daily protocols is absolutely crucial. Missing even a small number of doses can allow a drug-resistant strain of HIV to resurge, thus undermining or eliminating the effectiveness of the treatment. In circumstances where a patient is unable to comply with medical protocols, it is incumbent on the physician to work with the patient to find alternative therapies. My inability to explore and identify alternative therapies for unsuccessful medicines can cause patients to stop treatment altogether. I know of patients who have terminated potentially life-saving treatment because the side effects of their treatment seemed to them worse than the disease.
16. Before the government issued public threats against physicians, I discussed the medical use of marijuana with seriously ill patients who raised the issue. If patients had not tried other medications first, then it was my practice to recommend anti-emetics and/or Marinol. For patients who found other medications unsatisfactory, and for whom I believed medical marijuana could be, on the whole, beneficial, I provided counsel on the risks and benefits associated with various means of ingestion.
17. I am struck by the vehemence with which federal officials have attacked both treating physicians and the seriously ill patients who use medical marijuana. Those who suffer from chronic and severe illnesses need, above all, a broad range of therapeutic options from which to select a treatment (or treatments) that provide the greatest relief. In my experience, the government generally acknowledges this need. However, its recent policies (i.e., regarding cannabis) stray from its logical deference to medical reality. Recent pronouncements by the DEA and the Department of Justice contradict and belie the spirit of their official stance regarding experimental drugs, off-label use of drugs approved for limited purposes, and compassionate use protocols for experimental drugs which, while promising, are still in the early stages of testing. For example, the Food and Drug Administration permits AIDS physicians like myself to prescribe a variety of experimental drugs. Although early reports are promising, little is known with respect to their efficacy or the long-term effects.
18. Protease inhibitors, currently the most promising drugs in the fight against AIDS, fall within this category. Historically, the FDA has made provisions for physicians to prescribe drugs for conditions other than those for which they were initially approved. The FDA also has a compassionate use protocol which makes available to seriously and terminally ill patients those medications whose efficacy has not yet been scientifically demonstrated. Even if the FDA chooses to ignore medical experience and continue its prohibition against marijuana, it is remarkable that marijuana has not been made available under these provisions.
19. Marinol, which is essentially a marijuana derivative, has been approved for several years. Therefore, common sense tells us that there is a presumptive medical benefit to be derived from cautious use. Moreover, despite clinical studies (admittedly limited, yet far more extensive than those conducted on other FDA-approved substances), no credible research has revealed serious health risks which would justify the restrictions currently in place.
20. I have practiced medicine for almost 30 years. In that time, I have never been subjected to intimidation on the level of General McCaffrey's recent threats. I have worked hard to establish relationships with my patients that facilitate effective treatment and safeguard their privacy and integrity. The proscription against recommending the private use of marijuana, or even providing clinical information about the known risks and benefits, compromises my ability to provide sound medical treatment and relief from human suffering.

I declare under penalty of perjury under the laws of the United States of America and the State of California that the foregoing is true and correct to the best of my knowledge, and that this declaration was executed in San Francisco, California, this 13th day of February, 1997.

Milton N. Estes, M.D.