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Dressings can be changed less frequently as the wound becomes cleaner and starts to heal order generic mildronate symptoms juvenile rheumatoid arthritis, again reducing the risks of contamination or cross infection buy mildronate 500 mg fast delivery symptoms quitting tobacco. The number of invasive devices used on a patient must be kept to a minimum as far as possible buy genuine mildronate on-line treatment room. As Page 14 Module 1 Decontamination In addition to the precautions taken by all staff at Items that require decontamination are divided all times, standard decontamination techniques are into three categories, based upon the degree of risk also essential. Decontamination procedures, when involved in their use: carried out appropriately, play an important part in preventing and controlling nosocomial • Critical items are those which come into close infections. Unfortunately, the consequences of contact with a break in the skin or mucous failed decontamination – for example, an outbreak membranes, or those which are introduced into a of infection – can be very serious. Thus, it is sterile body area, for example, into tissues or the essential that all healthcare workers realise the vascular system. Any items used for these purposes importance of ensuring that items are safe for should be purchased sterile and sterilized patient use. Decontamination includes the following: • Cleaning means the removal of all visible dust, • Semi-critical items are items that come into soil, other foreign material and removal of sufficient contact with intact skin, mucous membranes, or numbers of microorganisms to reduce risks for body fluids, particularly if the items are used on those who handle the object or an area. Effective immunocompromised patients or those being methods of cleaning and drying have been proven cared for under isolation or transmission-based to limit cross infection in all healthcare settings, precautions. For spillages of blood and other body fluids, nosocomial infections, some organisms survive in the see universal precautions. Periodic cleaning of other sites close to patient areas such as ward kitchens and staff areas is also Routine cleaning important. Floors, toilets, and any equipment or furniture that is frequently handled by staff or patients should Equipment and surfaces that are hard to clean due be cleaned daily with a general detergent, hot clean to their poor condition can be a source of water, clean cloths, and/or mops. Maintenance and contaminated sites should be cleaned immediately; repairs are therefore essential. General detergents should be dispensed from their containers for use each day and kept covered to prevent contamination and to keep the solution fresh. Routine disinfection is not required and is more costly than using a general detergent. Periodic cleaning Periodic cleaning using the above-mentioned materials, is recommended for ceilings, walls, curtains, blinds, windows, shelves, cupboards, containers, and any other areas not cleaned daily. However, cleaning of some of these items is necessary and provides an aesthetically Page 16 Module 1 Disinfection methods Chemical disinfection are metal instruments including specula and There are many different chemicals that can be used sigmoidoscopes. Their effects on microorganisms method, which use wet heat at temperatures of vary. A chemical disinfectant must be able to withstand powerful water jets and is a compound or mixture capable of destroying alkaline detergents, for example reusable anaesthetic microorganisms. Effective chemical disinfectants include: • clear soluble phenolic compounds; • quartenary ammonium compounds; • chlorine releasing agents; • iodophors; • alcohols; • gluteraldehyde 2%; • demand-released chlorine dioxide; • stabilized hydrogen peroxide 6%; • peracitic acid; and • hypochlorites. It should be noted that some disinfectant products are designated for specific use, for example, skin disinfectants, environmental disinfectants, or instrument disinfectants. A careful assessment should be made to ensure that the appropriate disinfectant is used. Moist heat disinfection and pasteurization These two methods kill most bacteria and viruses. A typical cycle in an appropriate disinfector is at 73° C for a period of not less than 10 minutes. Moist heat disinfection by boiling is also a common and effective method, which will kill Page 17 susceptible microorganisms. A typical process is exposure to soft water boiling at 100° C for 5 minutes or more. Suitable items for this process Page 17 Sterilization methods Autoclaving, or steam under pressure, is one of guidance protocols should be followed. Many the most effective disinfection measures, rendering different types of sterilizers and disinfector bacteria, their spores, receptacles are available from manufacturers and and viruses non- the manufacturer’s instructions must be followed. Time/temper- • Frequent testing and monitoring of ature combinations decontamination devices is essential to ensure that are: 121° C for 15 the devices are able to fulfil their purpose and are Autoclave. Hot air oven: recommended time/temperature combinations for this are 160° C for 2 hours, • Chemical indicator tape is used to identify 170° C for 1 hour and 180° C for 30 minutes. Biological indicators are However, it can be used when items may be required to show this. Instructions combinations vary from 20–60° C over periods specifying the dilution of liquid disinfectants to of 2–24 hours. This method is useful for the proper concentration should be followed unwrapped delicate items that are heat sensitive, closely. Note that wet items may produce over- such as fibre-optic endoscopes and reusable dilution when added to solutions. There are many hazards should be made up each time they are required for associated with use of ethylene oxide including its use. It is also important There are many additional factors to consider when not to overload autoclaves. Risk technical personnel, provides convenience and assessments must be carried out and manufacturers’ simplifies quality control efforts. Page 18 Module 1 Decontamination when resources are limited • Where required, the disinfection of potentially As mentioned earlier, medical items are generally infected linen should be carried out using a classified as: combination of high temperatures and appropriate • reusable and intended for decontamination disinfectants. Autoclaving of surgical linen, such processes; or, as drapes, is essential in order to make them sterile • disposable, that is, usually made of inexpensive before use. General concerns and points related to Unfortunately, in some healthcare settings, material decontamination: and financial resources are limited and thus items intended for single use must be reused, and thus • Use of clean water for all patient care procedures must be decontaminated. Boiling or that such practices will most probably not make filtration of water may be required. Decontamination water should be used if available, especially for the procedures themselves can also affect the integrity rinsing of items after disinfection has been carried and function of single use items, making them out. Items should only be used for the purpose intended • Decontaminated items should be stored in such by their manufacturer. The items situations include: should then be stored in a clean area and dated so that if they are not used by a set time, they can be Disinfection of used gloves reprocessed for disinfection. Healthcare workers must wear gloves • Protection of healthcare workers while carrying when disinfecting gloves. Soak the infected gloves in out any method of decontamination is extremely a container for 10 minutes to decontaminate them, important. Health workers should be instructed and then remove them and wash them inside and in the minimal handling of contaminated items out with a cleaning solution. Chemical disinfection or autoclaving may also be suitable for some types of gloves. Page 19 Module 1 Page 19 Isolation or transmission-based precautions Reprocessing of needles and syringes All of the measures discussed this far (universal It is strongly recommended that needles and precautions, standard precautions and decontamin- syringes be used only once. There are times, however, when the risk transmission through improperly processed needles of nosocomial infections is greatly increased, due and syringes. Isolation precautions are now based on the means of transmission rather than the disease. In addition, this updated information highlighted the fact that many patients who have been infected or colonized with certain organisms could be cared for under universal or standard precautions alone (see Appendix 1).

Gender bias in cardiovascular testing persists after adjustment for presenting characteristics and cardiac risk discount mildronate line symptoms high blood sugar. Considering ‘‘the professional’’ in communication studies: Implications for theory and research within and beyond the boundaries of organizational communication buy generic mildronate on line medications 3605. Undergraduate students’ attitudes to communication skills learning differ depending on year of study and gender quality 250 mg mildronate treatment pancreatitis. Relationship between communication skills training and doctors’ perceptions of patient similarity. A spatial analysis of variations in health access: Linking geography, socio-economic status and access perceptions. Patient satisfaction: African American women’s views of the patient-doctor relationship. Characteristics of online and offline health information seekers and factors that discriminate between them. 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Role of patient treatment beliefs and provider characteristics in establishing patient–provider relationships.

Routes may deviate to other countries that lie along the routes and there are numerous secondary flows that may not be reflected generic mildronate 500 mg line medicine 802. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations order generic mildronate medications via g tube. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan order generic mildronate symptoms of pregnancy. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. Notes: The trafficking routes represented on this map should be considered broadly indicative and based on data analyses rather than definitive route outlines. Such analyses are based on data related to official drug seizures along the trafficking route as well as official country reports and responses to annual report questionnaires. Routes may deviate to other countries that lie along the routes and there are numerous secondary flows that may not be reflected. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. This points to an overall shrinking of the the burden on the health and criminal justice systems need cocaine market, although the number of (recreational to continue to be monitored regularly, recent data from rather than regular) cocaine users in several emerging mar- the states that have legalized marijuana for recreational use kets continues to rise. Given the global population and new psychoactive substances growth, this has gone in parallel with an increase in the total number of cannabis users since 1998. Since 2009, sumption regions for cannabis herb, with about three quar- global amphetamine seizures have fluctuated annually ters of all cannabis herb seizures worldwide taking place between about 20 and 46 tons, while “ecstasy” seizures in the Americas in 2014, the largest amounts in North more than doubled in 2014, to 9 tons, compared with the America, while Africa accounted for 14 per cent of all can- annual averages of 4-5 tons since 2009. Since 2009, those subregions together Member States on the sources of cannabis resin seized. Note: The origins of the flow arrows do not necessarily indicate the source/manufacture of methamphetamine. Flow arrows represent the direction of methamphetamine trafficking and are not an indication of the quantity trafficked. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir Note: The origins of the flow arrows do not necessarily indicate the source/manufacture of methamphetamine. Flow arrows represent the direction of methamphetamine trafficking and are not an indication of the quantity traf- ficked. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. Between 2012 and 2014, most substances reported methamphetamine seizures each year, whereas between for the first time belonged to the group of synthetic can- 2009 and 2014, methamphetamine seizures reported in nabinoids, but the data reported for 2015 so far show a East and South-East Asia almost quadrupled. There is a growing number substances (21) not belonging to any of the major groups of users of crystalline methamphetamine in the region, as identified in previous years were reported for the first time, well as increased frequency of use among certain user which included synthetic opioids (e. However, global seizures of synthetic cathi- nated in Lebanon and the Syrian Arab Republic. Over the nones have been steadily increasing since they were first same period, some countries reporting amphetamine sei- reported in 2010, with seizures tripling to 1. Although data stay for several years) and change (a considerable number collection for 2015 is still in progress, 75 new substances of substances appear for a short time or only locally). The analysis of the drug problem, Low Medium High Very high and the response thereto, through the lens of the Sustain- Human development index able Development Goals reveals the mechanisms of this Global average By level of development interaction. All areas of sustainable development, as identi- fied in the 17 Sustainable Development Goals, shape the Sources: Human development index from the United Nations nature and dynamic of the drug problem. In analysing those linkages, the 17 Sustainable Development Goals have been divided into million were linked to opioid use disorders. One of the five broad areas: social development, economic develop- risk factors for the negative health impact of drugs stems ment, environmental sustainability, peaceful, just and from their mode of administration. Some studies also corroborate the hypothesis that the use of certain stimulants (whether injected or not) The failure to accept or understand that drug dependence may also influence sexual behaviour itself, thereby increas- is a health condition feeds the cycle of marginalization ing the likelihood of high-risk behaviour and sexual trans- that often affects people with drug use disorders, making mission — a pattern that raises concern particularly in the their recovery and social integration more challenging. Three quarters of the global population still have little or no access to medicines containing narcotic drugs The Global Burden of Disease Study indicates that opi- and have inadequate access to treatment for moderate to oids, cocaine, amphetamines and cannabis together severe pain. There are marked differences between End poverty in all its forms male and female drug users in terms of preferred drugs everywhere and drug-related vulnerabilities. Coupled with the fact that users of several drug types are predominantly male, this leads to a danger that the entire continuum of care may fail to cater adequately for the needs of female drug The toll taken by the drug problem may vary in size and users, who also have a lack of access to such services. Achieve gender equality and empower all women and girls The relationship between economic development and drugs is particularly evident in the case of the illicit culti- vation of drug crops. They suffer levels of development which, alongside other development from co-occurring mental health disorders to a greater issues linked to security and governance, are enabling extent than men, and they are more likely to have been elements of large-scale illicit cultivation. Women often also bear a heavy burden of violence and deprivation associated with Higher socioeconomic groups have a greater the drug dependence of family members, hindering the propensity to initiate drug use than lower achievement of the sustainable development target of elim- socioeconomic groups, but it is the lower socio- inating all forms of violence against all women and girls. Female offenders and prisoners, especially those with drug economic groups that pay the higher price as use disorders, face particular hardship as, in many they are more likely to become drug dependent instances, criminal justice systems are not yet equipped for the special needs of women. Poverty also has strong links with drug use, albeit in a complex and mutually reinforcing manner. Indeed, the Drug use often affects people during their most produc- brunt of the drug use problem is borne by people who are tive years. When youth become trapped in a cycle of drug poor in relation to the societies in which they live, as can use, and even in the drug trade itself, as opposed to being be seen in stark terms in the wealthier countries. This pat- markets for certain substances, notably cocaine and syn- tern can also be seen when looking at different reflections thetic substances, have taken hold in developed countries of marginalization and social exclusion, such as unemploy- before subsequently expanding to developing countries. Proximity to a drug-producing between development and the drug problem thus needs area or a major drug trafficking route can, for example, to be viewed in dynamic terms. Take urgent and income” countries tend to have a higher prevalence of significant action to reduce the past-year drug use across the drug categories. Drugs that degradation of natural habitats, can command a relatively high price, and ultimately higher profits for traffickers, find an easier foothold in countries halt the loss of biodiversity and, by with relatively higher levels of per capita income. In the 2020, protect and prevent the case of substances such as cocaine and heroin, the level of extinction of threatened species economic development contributes to the formation of consumer markets that are large in terms of both number Illicit crop cultivation often occurs in forested areas and of users and total revenue. Moreover, illicit crop cultivation frequently Different levels of socioeconomic well-being within indi- takes place in biodiversity hotspots hosting a large number vidual countries also have an effect on the type of drugs of species with a limited habitat, some of which are pro- used.

Yet purchase 250mg mildronate overnight delivery symptoms 1 week before period, these efforts are nascent purchase generic mildronate pills medicine 319, localized buy mildronate canada 340b medications, and not necessarily scalable (Watts et al. Commitment to creating a high-value patient experience is required in order to affect real change in institutional practices and outcomes. Although leaders are well meaning, too often they lack simple awareness of alternative approaches, or, if known, there is a lack of commitment to do the hard work of system redesign. Our organizations include a pediatric hospital, a safety net health care system, local and national integrated health care systems, an integrated community-owned health system, and a managed care health care system. Although our organizations differ in size, populations served, and institutional constructs, these themes and the strategies described are broadly applicable to all of U. Accordingly, while examples are given from some institutions, each of our institutions employed these strategies, and they are broadly applicable in health care. Attention to the barriers to flow and removing waste will increase capacity, enable timely care delivery, and improve care. It must be noted that these approaches were part of a larger, comprehensive effort to redesign care delivery. It should be underscored that efforts to improve access within our organizations are ongoing. Our organizations are committed to continuous process improvement and recognize that improvement is not static but rather an iterative process. As such, the examples contained within this discussion paper often reflect efforts within a single service line, practice, or geographic location. It is widely recognized that much more remains to be done before effective scheduling and access is a systemwide characteristic. That being said, and recognizing the unique constraints of each organization, three overarching principles are common throughout all of our efforts: the application of a systems-thinking approach, the use of a disciplined methodology for system redesign, and a foundation of respect for people. A common strategy of our organizations was the consideration of our institutions as complex systems. Tantamount to determining how to best implement change and mitigate unanticipated outcomes was recognizing that, rather than discrete environments or services, our organizations are complex groups of interdependent processes, personnel, and incentives. For example, looking beyond the immediate problem of delayed clinic visits enabled us to see problems with referrals for subspecialty appointments, difficulties with weekend discharges, or inadequate communication during appointment requests. A systems-level approach ensures that all aspects of a complex system are considered, including how the system elements interact with one another over time. Our organizations used system-thinking strategies to tackle access challenges, and they all used a disciplined methodology, albeit different methods, to ensure that improvements would be effective, efficient, and provide value to patients and their families and the organization. The two best known approaches, Lean and six sigma, are management philosophies and tools successfully used in other industries that are now being adopted in health care. Lean focuses on eliminating waste from the patient perspective to achieve uninterrupted flow from the beginning to end of the process. Six sigma is another management technique aimed at eliminating defects by reducing variations, in order to enable more capable products and processes (Revere and Black, 2004). The use of a disciplined approach removes blame and politics from process improvement, and focuses priorities on improvement for the patient or family. An underlying characteristic of our health care organizations is a respect for peoplefor everyonepatients, families, and the many people that keep our health systems running. Patient and family needs are placed at the center of the care process, and they are involved in the redesign of our health care system. They are encouraged and enabled through system design to become stewards of their own health. Too often respect for patients or patient engagement amounts only to empty words; however, for our organizations, moving to a culture of respect was key to our system redesign. It provided a principle to guide every decision, every change, and every interaction. As a pillar of Lean philosophy, respect for people also refers to those working in our medical practices or hospitals. This includes a culture that gives everyone the 11 tools and the opportunity to become problem solvers; enhances individual creativity, values teamwork; and engenders communication, trust, and respect between frontline staff and senior levels of management. Sophisticated analytics were applied using demographic, clinical, and pharmacy data and recent utilization information to categorize patients into levels of care to better define their needs for enhanced primary care services. They discovered that within Denver Health’s population of about 130,000 clinic users, almost 80,000 individuals appeared to be largely healthy with few additional needs beyond being reminded to access regular preventive services. By contrast, just 2 to 3 percent of the adult population routinely accounted for 30 percent of total charges and tended to have multiple comorbid physical and behavioral health conditions and complex care coordination needs (Gabow and Goodman, 2015). Although it was clear that not all patients had the same needs, the existing model of care delivery provided care for all patients in same way, using the same care teams, same visit type, and same electronic connections. In subsequent efforts, Denver Health used these risk stratification data to redesign patient identification methods, care team staffing model, and the clinic visit standard work to better match patients’ needs and ensure appropriate access (Gianani and MacKenzie, 2000). Of note, many of the needs were for social services rather than health care services, given the vulnerable nature of those in urban populations. This allowed a transition from retrospective reviews of wait times to real-time monitoring, in order to allow for the rapid trialing of improvement techniques in the emergency department and the improvement of patient flow-through to the inpatient facility. Using techniques of Lean acquired during a leadership program studying the Toyota production system, Seattle Children’s was able to identify wasteful processes and implement efficient processes, including appointments for beds, real-time communication, and advanced planning techniques for hospital admissions. These initiatives have resulted in a 25 percent improvement in patient flow-through for admitted patients, with a secondary effect of decreasing wait times for patients not requiring admission. In an effort to minimize variation and wasted activity, processes are designed to consistently deliver the needed care for every patient, in every office, every time. Incorporation of new processes into reliable work flows has been seen as a critical step. Leveraging various data sets to provide just-in-time feedback to the team has helped Geisinger staff to identify gaps and areas of variation that need additional redesign. Improving Flow System redesign efforts at Kaiser Permanente focused on hospital delays, or internal waits. Beginning with elective surgeries, data aimed at reducing surgery backlog was collected on wait times. However, rather than directing their efforts to a specific area affected by delay, a systems view was adopted to look at the entire care pathway: preadmission, surgery, recovery room, and postoperative care. Likewise, following the implementation of Lean principles at Seattle Children’s outpatient center, Bellevue Clinic and Surgery Center, there have been multiple process improvements involving operating room access. By reviewing work flow and using standard work methods, scheduled operations now begin on time with a 99 percent success rate. Removing wasteful processes for patients with heart attack has dropped the “door-to-balloon” times at Thedacare in Wisconsin from the national average of 90 minutes to 51 minutes. Determining Capacity: Balancing Supply and Demand These examples underscore the untapped capacity that exists in our systems that can be uncovered via a variety of approaches, including applying standard work to provider templates; using the robust data that we have on patient demand by month, day, time, and patient type; redesigning clinic processes to maximize provider availability; and using non-face-to-face visits. At Seattle Children’s, the scheduling and wait time challenges for the ambulatory clinics were found to be both resource and process dependent.

At the global level purchase discount mildronate treatment nausea, drug-related offences persons mildronate 250 mg fast delivery symptoms and diagnosis, particularly the youngest and most vulnerable order mildronate on line amex symptoms gestational diabetes. It bery, motor vehicle theft, burglary and homicide, have also often increases social exclusion, worsens health condi- decreased substantially (see figure 22). Alternatives to incarceration that just under a third of the global prison population (30 within the community (in an outpatient or residential per cent over the period 2012-2014, compared with 32 therapeutic setting), such as psychosocially supported per cent over the period 2003-2005) continues to be made up of unsentenced or pretrial prisoners. Female offenders and prisoners, 120 especially those with drug use disorders, face particular figure 23). In many countries, the majority of children who are in detention are either children 6060 Rape (64 countries) affected by drug dependence or children who have com- mitted drug-related offences. Overreliance on the depriva- 4040 Robbery (61 countries) tion of children’s liberty and insufficient application of drug treatment programmes or other alternatives to deten- Motor vehicle theft (64 countries) tion are common challenges,188 despite international obli- gations to use the deprivation of liberty as a measure of Burglary (53 countries)Rape (64 countries)Rape (64 countries) last resort. Drug-related personal consumption offencesDrug-related personal consumption offences (43 countries)Burglary (53 countries) 185 Ralf Jurgens and Glenn Betteridge, “Prisoners who inject drugs: (43 countries) public health and human rights imperatives”, Health and Human Homicide (81 countries) Rights, vol. Source: United Nations Survey of Crime Trends and Operations of 186 “From coercion to cohesion” (see footnote 184). Notes: Trends are calculated as weighted crime rates per 100,000 popu- lation relative to the base year 2003. To produce global estimates, the 188 See the report of the independent expert for the United Nations estimated crime rates for each region were weighted according to theDrug-related personal consumption offences study on violence against children (A/61/299, para. Data on drug(43 countries) thematic report by the Special Representative of the Secretary-Gen- trafficking and drug-related personal consumption offences refer mostly eral on Violence against Children (Promoting Restorative Justice for to persons arrested or prosecuted for those types of crime. Deprived of their Liberty (General Assembly resolution 45/113, 191 Based on data from 74 countries, classifying convictions with multi- annex). This is in line Financial crimes or corruption with the international drug control conventions196 and Drug-related offences with the requirements of an effective penal policy that is Other offences/not known in compliance with human rights standards. The provision of evi- ficking” character of a drug-related offence; they can dence-based treatment and care services to drug-using include the drug type and amount, associated thresholds offenders, as an alternative to incarceration, has been (or none at all), drug purity, position in a gang and whether shown to substantially increase recovery and reduce recidi- the person in question uses drugs. This variation thus makes the comparison of data across countries challeng- 192 Each of the above-mentioned estimates has been calculated on the ing. Global aggregates show that the number of offences basis of the corresponding available data set and presented on the related to personal consumption exceeds the number of assumption that the data set is representative of the global popu- trafficking offences, reflecting the fact that the number of lation. However, the exact coverage, and hence the level of uncer- tainty, differs according to the specific indicator. Moreover, the stipulated periods of 195 See article 3, paragraph 4, of the United Nations Convention imprisonment tend to be longer for trafficking offences. More than three quarters 196 See article 36, paragraph 1 (a), of the 1961 Convention as amended of all persons held in prison for drug-related offences in by the 1972 Protocol, article 22, paragraph 1 (a), of the 1971 Con- vention and article 4 (a) of the 1988 Convention. This highest ranks of power, such as police chiefs, national poli- improves outcomes both for the person with the drug use ticians and high-level law enforcement officials. The prac- disorder and the community when compared with the tice of corrupting officials to facilitate drug trafficking has effects of criminal justice sanctions alone. Alternatives to imprisonment have sometimes been put in Corruption can also vary depending on the strength of place as a response to developments in drug use. For exam- the rule of law and the effectiveness of state institutions; ple, the spread of the use of “crack” in the United States characteristics of the political systems such as the strength in the 1980s was a major factor in prompting the intro- of political parties, the efficacy of the criminal justice duction of “drug courts”. Similarly, the challenging nature system, including its investigative and prosecutorial func- of the drug problem in Portugal in the 1990s set the scene tions, the existence of functioning oversight mechanisms for a turning point in Portuguese drug control policy, as and sanctions for corruption can reduce the extent of drug- well as the institutional setup for its implementation. The organization of criminal groups can also affect the specific interaction between state offi- Corruption, organized crime and illicit cials and criminal groups. In Italy, for example, studies financial flows have found that organized criminal groups with complex internal structures, such as Cosa Nostra and ‘Ndrangheta, Corruption whose activities include, but are not limited to, the illicit Target 16. In other parts of the country, organized criminal groups such as the Camorra and the Apulian groups, which are less hierarchical and strict in Corruption and related forms of crime such as extortion their recruitment practices, have more diffuse, though still engender costs in terms of discouragement or impediment strong, political connections. For example, according to a report by the General Accounting Office in the United States, less than There is a mutually reinforcing relationship between the 1 per cent of employees of the Custom and Border Patrol drug problem and corruption. The illicit drug trade often were arrested on charges of corruption between 2005 and flourishes where state presence and the rule of law are weak 2012; among the 144 employees arrested or indicted for and, thus, where opportunities for corruption exist. At the corruption, pressure from drug trafficking and other trans- same time, the profits and power of drug trafficking organ- national criminal groups was found to be a key factor. Of izations provide them with resources to reinforce corrup- the 144 cases, 103 were found to be “mission-compromis- tion by buying protection from law enforcement agents ing”, including instances involving drug trafficking or the — particularly when the agents’ levels of remuneration smuggling of migrants. There were 32,290 allegations of are low — and from politicians and the business sector; corruption or misconduct during the same period,203 this means that corruption can be the Achilles heel in the which shows that even though corruption may not response to drug trafficking. Low-level or “petty” corruption often starts with street police or local Drug trafficking organizations conduct their business politicians, who may be vulnerable to crime because of a using both corruption and violence. Criminals and drug lack of social legitimacy or because they come from the traffickers use those two strategies simultaneously, and very same communities as members of criminal groups. In many cases, such illicit proceeds protection that criminals might be unwilling to destabilize can inject large cash inflows into a country’s economy and through violence. Predictable cor- countries, some of which have been significantly affected rupt networks — those that guarantee protection from by cocaine trafficking. In Guinea-Bissau, for example, law enforcement — can deter criminals from deploying foreign exchange reserves rose from $33 million in 2003 large-scale violence. Such networks may be more likely to to $174 million in 2008; and in the Gambia, the value of emerge where government power is centralized and the the dalasi increased very rapidly with no clear change in capital inflows. This, in turn, may deter the use of violence they may undermine the integrity of a country’s financial because criminals may prefer to avoid violence, as that system, including its international financial sectors. In the could force the government authorities to target them case of opiates originating in Afghanistan, for example, a more strongly. The transfer of funds between consumer markets and Drugs and illicit financial flows intermediate countries varies significantly, with drug traf- fickers using the full range of money transfer techniques, Target 16. How- arms flows, strengthen the recovery and return of ever, funds moving between intermediate countries and stolen assets and combat all forms of organized Afghanistan seem to make particular use of cash couriers crime and money or value transfer services. Profits from the illicit drug trade can constitute consider- Part of the proceeds from the illicit drug trade generated able financial incentives for organized criminal groups. The money originated from the ranging from the use of small, decentralized techniques, Sinaloa cartel in Mexico, the Norte del Valle cartel in Colombia and other smaller drug trafficking organiza- tions. Durán-Martínez, “Drugs, Violence, and 209 West Africa Commission on Drugs, Not Just in Transit: Drugs, the State-sponsored protection rackets in Mexico and Colombia”, State and Society in West Africa (2014). However, over the same Given the extensive interplay that exists between sustain- period, the magnitude of commitments towards the sectors able development and drug control, development assis- specific to drug-related matters, namely “alternative devel- tance and capacity-building must also be channelled into opment” (agricultural and non-agricultural)214 and “nar- measures to counter the world drug problem. Assistance in these sectors, particularly in the “narcotics control” The efforts of the international community in countering sector, increased substantially after 1998, when the twen- the world drug problem have long recognized the impor- tieth special session of the General Assembly, devoted to tance of partnership as embodied in the concept of countering the world drug problem together, was held. Moreover, while the “narcotics control” sector Problem”, which defined action to be taken by Member dominated the drug-related total over the period 1999- States as well as goals to be achieved by 2019. At the 2016 2008, the decline in that sector was so steep that assistance session, Member States adopted the outcome document in the “alternative development” sectors, even though sig- entitled “Our joint commitment to effectively addressing nificantly lower than in the peak years of 2007 and 2008, and countering the world drug problem”. Expressed as a percentage of total development assistance, total assistance to the above-men- tioned drug-related sectors reached its highest level (2. A range of communica- tor Reporting System is not categorized under the sectors tion platforms continue to be used extensively to exchange discussed above, may also contribute, directly or indirectly, information between law enforcement agencies.

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