Harm Reduction in South, South East and East Asia

Author: Jimmy Dorabjee

Introduction
The Asian region is home to more than half of the total Global population. The two most populous countries in the world, China and India, the upcoming economic tigers of the region, lie in Asia. The two largest illicit opium producing regions of the world, the Golden Triangle and Golden Crescent, are located in South and South East Asia, ensuring the abundant and widespread availability of opium and its alkaloids morphine and heroin. In addition, India, which until a decade ago was the world’s largest producer of licit opium for medicinal purposes, also contributes a proportion to the domestic market for illicit opiates. Until the mid 1970’s, cannabis and opium were the two most common drugs that were traditionally used across Asia, predominantly through oral ingestion. In the past 15 years, South East Asia has witnessed an explosive increase in the use of Amphetamine Type Stimulants (ATS) especially among the younger population and the use of ATS continues to grow unabated.

This article describes the development of harm reduction in South, South East and East Asia. In this article, Asia refers to twenty six countries stretching from Afghanistan in the west to China in the east. Except for a handful of small scale NGO run programs in a few countries in the 1990’s, harm reduction emerged late in the Asian region as a response to the threat of widespread HIV infection among people who inject drugs (PWID) and from them to their sexual partners and the general community. Further, harm reduction became reluctantly acceptable to Asian governments only after a series of explosive HIV epidemics among PWID had already been well established and continued to spread to new populations in several countries. Despite a growing acceptance of the effectiveness of harm reduction as a public health approach to HIV prevention and control, the coverage of harm reduction programs is unable to match the explosive spread of HIV and hepatitis C infection in PWID.

HIV infection in PWID was first detected in Bangkok, Thailand. In 1988, the prevalence of HIV infection rose from <1% to ~ 40% among injectors in Bangkok (Kitayaporn, 1998) In 1989, 146 inmates of a drug detoxification centre in Ruili County, Yunnan Province, Peoples Republic of China tested positive for HIV (Ma et al, 1990) and later that year, the first case of HIV in PWID was documented in Manipur State, North East India. Since then, HIV epidemics among the PWID have been documented in almost all the countries in the region. With an estimated 5.5 million people who inject drugs in the Asian region (Mathers et al, 2010) and poor access to even the most basic of harm reduction tools such as sterile syringes and Opioid Substitution Therapy, the sharing of contaminated injecting equipment has played a driving role in the initiation, acceleration and perpetuation of HIV epidemics in many Asian countries. Thailand, Malaysia, Myanmar, Nepal, Cambodia, China, Vietnam and Indonesia continue to document high prevalence of HIV among PWID. Historical Perspective Since time immemorial the use of mind altering substances was common and countries in the Asian region including Cambodia, Vietnam, Thailand, Laos, China, Nepal, Bangladesh and Pakistan have been traditional consumers of cannabis and opium, with cultural norms restricting the use of cannabis and opium to the adult male population, (Charles et al, 2005, UNODC, 2007, WHO, 2001). In India and Nepal cannabis use has been linked to Hindu religious festivals like Shiv Ratri and Krishna Ashtami – the birth of Lord Krishna and participation in bhajan (religious chanting) sessions. Indeed, occasions like Holi, ‘the festival of colours,’ are not complete without the sharing of a traditional offering of bhang – a drink made with crushed cannabis leaves. Opium is also offered at the harvest festival in a ceremony called ‘akha teej’, intended to strengthen family marital clan bonds and put aside old feuds( WHO, 2001). In rural Myanmar, opium was an integral part of the culture, used in religious festivals and for medicinal purposes (UNAIDS/UNODCCP, 2000). While the use of opium and cannabis was culturally accepted, traditional forms of opioids began to give way to the aggressive marketing of heroin from the Golden Triangle and Golden Crescent regions. The high purity of heroin manufactured in the SE Asian region, coupled with the reduced availability of opium, resulted in a switch from oral use of opium to heroin injecting, a more efficient and cost effective mode of drug use. The cruder, less refined products from the Golden Crescent region were more suited to inhalation and by the mid 1980’s, cheap and abundant supplies of dark brown heroin, known locally as smack or brown sugar, flooded South Asian markets. Impact of drug control laws and polices The legal and political environment determines national responses to drug trafficking and use within their borders. The introduction of stricter drug control laws and policies in Asian countries resulted in a significant decline in the use of culturally sanctioned traditional drugs and the introduction of harder drugs and the injecting of drugs. In 1976, over three decades ago, Joseph Westermeyer’s prophetic paper titled ‘Pro heroin effects of anti opium laws’ alerted us to the unintended negative consequences of law enforcement initiatives that followed the introduction of strict anti opium laws in Hong Kong, Laos and Thailand. Westermeyer commented that all three countries followed a pattern that began with government passing and enforcing laws banning the production, sale and use of opium under pressure from North American, European and international interests. He noted that within a decade, most of the former opium users in Hong Kong and Thailand switched to the use of heroin and all new recruits began with heroin rather than opium. The pattern was striking as not only did it occur in three different locations but also at three different decades, beginning in Hong Kong during the late 1940s and 1950s, in Thailand during the 1960s and in Laos during the 1970s suggesting a causal relationship between the new narcotic laws and heroin use (Westermeyer, 1976). Since then, many Asian countries including Pakistan, Thailand (McCoy, 1991), India Charles et al, 2005), Nepal, China and Indonesia have enacted tougher anti narcotics laws under intense pressure from the West and the UN conventions, resulting in the lower availability of traditional drugs such as opium. The enforcement of the harsh Narcotics and Drug laws and stricter control measures over the relatively harmless traditional drugs that were used orally set the stage for the emergence of widespread heroin injecting, followed years later by the large scale use of Amphetamine Type Stimulants. For example, India introduced the Narcotic Drugs & Psychotropic Substances (NDPS) Act in 1985. Within a few years, local opium dens and cannabis outlets disappeared and reports of the widespread smoking of heroin in major metropolitan cities began to appear, with some heroin injecting. A few years later when law enforcement activities reduced the availability of heroin, the injecting of licit buprenorphine and other pharmaceutical drugs such as diazepam, chlorpheneramine maleate, promethazine, pethidine and dextropropoxyphene began across the country (Kumar and Daniels, 1994, Dorabjee and Samson, 1998, Bharadwaj,1995, Biswas et al, 1994, Kumar et al, 2000) While heroin continued to be freely available in the North Eastern States of India bordering Myanmar, drug users in metropolitan cities of Delhi, Chennai and Kolkata started to inject pharmaceuticals such as buprenorphine, often cocktailing with antihistamines and benzodiazepines which were easily available over the counter in chemists Dorabjee and Samson, 1998) Bangladesh and Nepal have witnessed similar patterns of heroin use followed by epidemics of buprenorphine injecting that began in South Asia and continues till today. The evidence suggests that the new legislation exacerbated the problems arising from such structural changes and far from reaching its goal of eradicating drug use, enforcement of the Indian NDPS Act (1985) appears to have inadvertently facilitated a shift to harder drugs and riskier modes of consumption (Charles et al, 2005, Dorabjee and Samson, 2000) In Thailand, the tough enforcement policies against opium in the 1970s led to the substitution of opium with injected heroin (McCoy, 1991, Westermeyer, 1976). The history of opium use in China has been documented since the 17th century. It was estimated that more than 100 million people smoked opium in China in the early 20th century and about 15 to 20 million were considered addicted to opium. With the foundation of the People’s Republic of China in 1949, the Government under Mao’s leadership implemented programs that effectively reduced opium trade and use for three decades. In the late 1970s China introduced its “open door” policy and with increased trade of licit goods, the trade in illicit goods, including narcotics, re-emerged. With its borders in close proximity to the Golden Triangle and Golden Crescent, China became a major transhipment route for heroin trafficked to western countries, reporting some of the world’s largest seizures of heroin, 10.8 metric tonnes seized in 2004 (UNODC, 2006). The trafficking of large amounts of heroin through China facilitated easy availability of the drug to local markets leading to China becoming a major consumer of heroin, with use concentrated in the provinces that shared borders with the countries of the Golden Triangle. Although opium is still used, the injecting of heroin has become widespread in China and heroin remains the most popular drug of choice today. Apart from heroin, drugs such as amphetamine-type stimulants (ATS), diazepam, Bingdu (methamphetamine) or Maguo (a derivative of methamphetamine), ecstasy and ketamine are popular. Drug users in China are required by law to be registered with the authorities and the number of registered drug users in China increased from 70,000 in 1990 to 1.3 million in 2009. However, registered drug users comprise only a fraction of the actual number which is estimated to be between 6 to 7 million, the majority of whom inject heroin. Traditional responses to drug use With deterrence and punishment the focus of drug policy and abstinence the predominant philosophy of drug dependence treatment in SE Asia, the region has seen a proliferation of compulsory drug treatment centre’s managed by the police, army or other uniformed services. South Asia has followed a balanced approach of prevention, treatment and care with an abundance of detoxification and rehabilitation centre’s funded by international organizations and governments in a variety of hospital settings, psychiatric wards and NGO run rehabilitation centre’s. Governments in South East Asia have responded to illicit drugs by the criminalization of drug use and have adopted particularly harsh policies in response to drug use and trafficking (WHO/WPRO, 2009). Dependent drug users are considered to be criminals and are subjected to disproportionately severe punishments meted out including detention in compulsory centers for extended periods of time. Even where policy changes have mandated that drug users be viewed as patients in need of medical treatment, periodic law enforcement crackdowns on drug use and users have continued, highlighting the disconnect between public health and drug control policies, and undermining access to harm reduction services. International and Regional Drug Control Frameworks as well as individual country’s national drug laws effect harsh penalties for possession and use of illicit drugs. Several countries in the region including China, Indonesia, Lao PDR, Malaysia, Singapore, Thailand and Vietnam still retain the death penalty for drug offences (HAARP, 2009). A major barrier to the introduction of evidence informed approaches and harm reduction has been the positions taken by influential regional bodies such as the Association of South East Asian Nations (ASEAN) declaring the aspiratory goal ‘A drug free Asia by 2015″, and the UNODC’s slogans such as “A drug free world-we can do it” that have spurred Asian countries to bear down heavily on drug use and conduct a “war on drugs” approach which has translated into a ‘war on drug users’ across the region. The most infamous example of the ‘war on drugs’ occurred in January 2003, when the Thai government of Prime Minister Thaksin Shinawatra announced an aggressive “War on Drugs” aimed at stopping all illicit drug supply and trafficking in Thailand, treating all known drug users and involving communities in monitoring and preventing drug use. Blacklists containing 329,000 names of people supposedly involved in the drug trade were compiled by the police, village heads and the Office of the Narcotics Control Board. By the end of April 2003, some 2,637 people had been killed, of whom 68 were shot by the police claiming it was in “self-defense” (Siam Voices, 2011). More than 250,000 drug users were treated in health care settings or military type camps. It is ironical that the International Harm Reduction Associations 14th International Conference on the Reduction of Drug Related Harm was held in early April of 2003 in Chiang Mai, Northern Thailand while this campaign was at its peak. International Drug Control Frameworks Regional Drug Control Frameworks The Single Convention on Narcotic Drugs (1961): All practicable measures for the prevention of abuse of drugs and for the early identification, treatment, education, after-care, rehabilitation and social reintegration of the persons involved. ASEAN and China Cooperative Operations in Response to Dangerous Drugs (ACCORD): In Pursuit of a Drug-Free ASEAN and China 2015, a plan of action to address both the demand and the supply of drugs. The Convention on Psychotropic Substances (1971): Controls over a number of synthetic drugs according to their abuse potential. ASEAN Senior Officials on Drug Matters (ASOD): A plan of action for drug control The Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances (1988): Appropriate measures which includes interventions to counteract the social and health consequences of drug dependence Memorandum of Understanding (MOU) on Drug Control: China, Lao PDR, Myanmar, Thailand, Vietnam and Cambodia – a drug control framework that encompasses the Greater Mekong Region China, Indonesia, Malaysia and Philippines (2004) Source: Kumar, S. and Dorabjee, J. (2012) Compulsory centers for people who use drugs in Southeast Asia: looking for alternatives, draft report Compulsory drug treatment centers for people who use illicit drugs currently exist in eleven countries across Asia. Cambodia, China, Indonesia, the Lao People’s Democratic Republic, Malaysia, Thailand and Vietnam operate compulsory drug treatment centers and re-education through labor centers for drug users (WHO/WPRO,2009) that are akin to prison settings. Country Nature of “Compulsory Treatment”provided Number detained (12 months) Number detained at any one time Brunei Darussalam 1 Mandatory drug rehabilitation facility. Not known Not Known Cambodia 14 compulsory camps. 1505 – 1719 Not Known China 700 compulsory detoxification centers, 300 re-education through labor camps. 300,000 Not Known Iran (Islamic Republic of) Temporary compulsory rehabilitation centre’s reported but number unknown. Not Known Not Known Lao Peoples Democratic Republic 7 compulsory drug rehabilitation centers involving drug detoxification. Not Known 833 Malaysia 28 compulsory drug treatment centers. Not Known 6848 Myanmar 26 major and 40 minor compulsory treatment centers. 1,492 Not Known Thailand 90 compulsory treatment sites 40,680 Not Known Turkmenistan 1 compulsory detention site 6,546 Not Known Viet Nam 109 centers with entry via committal by family, the community or arrest for drug possession Not Known >60,000
Source: Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector. Progress Report, 2010, WHO, UNAIDS, UNICEF.

In Vietnam, around 50,000 drug users were residents in compulsory rehabilitation centers (known as 06 centers) nation-wide in 2007, about 25% of total number of drug users in the country, with about 30,000 of these in Ho Chi Minh City. The terms of commitment in the 06 centers have increased to 5 years in Ho Chi Minh City and generally 2 years elsewhere. China and Vietnam continues to treat drug use as a ‘social evil’ and responses such as crackdowns, mass arrest, forced detoxification and incarceration of drug users are common. Enforcement strategies include arrest quotas for beat police, use of paid informants and bounties for turning in dealers and users, besides the further expansion of compulsory detoxification centers and re-education through labor camps (Hammett et al, 2007).

In China the Standing Office of the National People’s Congress enacted the “Regulations on Prohibition against Narcotics” that specified three levels of management of drug use. In the first, drug users are sent to detoxification centers managed by the Ministry of Public Health for a period of 7-30 days (Qien et al, 2006). In case of relapse following detoxification at these centers, they are sent to compulsory detoxification centers administered by the Public Security Bureau, where they spend at least 6 months participating in a combination of detoxification treatment, physical exercise, and manual labor. Those who relapse after compulsory detoxification are mandated to undergo 2 to 3 years of re-education through labor centers administered by the Justice Bureau. Drug users are not allowed to leave the compulsory detoxification centers and labor camps. The “Regulations on Prohibition against Narcotics” states that the main reason for the detoxification centers is to reduce demand for drugs and their use, drug related crimes and to prevent the transmission of HIV. Yet, there is no evidence that those who receive frequent detoxification change their HIV related injecting and sexual risk behaviours. There were reported to be 746 compulsory drug rehabilitation facilities and 168 Rehabilitation through Labor Centers with a population of 200,000 and 120,000 respectively in 1999. In June 2006 alone, 269,000 drug users were interned in rehabilitation centers and 71,000 of them were sent to reeducation through labor camps. With 1000 sites across China at the end of 2006, over 600,000 drug users had been admitted to these centers, most of whom (95%) were heroin users (Li et al, 2010).

Malaysia has traditionally imposed strict punitive measures with the widespread arrest and incarceration of drug users and the death penalty for trafficking offences. The 1952 Dangerous Drugs Act has regularly been amended to impose harsher penalties for illicit drug use. A zero-tolerance approach is practiced, with the laws authorizing police to detain those suspected of drug use for up to two weeks, force them to undergo urine testing, and to send those testing positive for illicit substances to compulsory treatment camps. Repeat offenders who are found in possession of any amount of illicit drugs face mandatory flogging and imprisonment. The possession of 15 grams of heroin or 200 grams of marijuana is punishable by death, and around 230 people have been hanged under this statute since 1975. In January 2005, authorities announced that possession of a syringe would be punishable with incarceration (WHO and Malaysian MOH, 2011).

The government run rehabilitation centers admit heroin dependents for 2 years of detention in a drug-free residential rehabilitation centre followed by 2 years of supervised parole. Relapse after discharge from these centers is very common. The failure of the custodial approach to stem drug use and HIV transmission led to the introduction in 1996 of some medical treatments which were limited to medically supervised detoxification and drug counselling.
The Malaysian government drug control agency estimated approximately 350,000 people who use drugs in 2004, and in 2008, the UN Reference Group estimated between 170,000 and 240,000 injectors (United Nations, 2008). Malaysia’s 31 prisons currently hold 36,040 people, and in 2007 about 40% of the prison populations were incarcerated on drug-related charges (HIV and AIDS data hub for Asia Pacific, 2010). There are at least 16 other detention centers, including drug treatment centers, illegal immigrants’ depots and juvenile institutions in Malaysia.

The arbitrary detention of people who use or are suspected of drug use, the mistreatment of detainees and the continued growth in numbers of compulsory drug treatment centers has drawn global attention to the existence of these centers in SE Asia. The lack of evidence supporting these approaches, the practice of repressive policies, violation of the right to health and human rights abuses in these centers has drawn criticism from human rights groups, civil society and the UN.

Below is the story of Jaa from Malaysia which was heard by delegates to the International Conference on the Reduction of Drug Related Harm in Bangkok, Thailand in 2009. It illustrates a common experience of inmates who have been through SE Asian rehabilitation centers.

Jaa narrated the horrors of mandatory rehabilitation in one of Malaysia’s28 drug rehabilitation centers. As a drug user, Jaa spent most of his adult life in and out of prisons and mandatory rehabilitation. “I have been into them 16 times” he cried “and I cannot begin to describe the 30 years experience and torture I faced in prisons and rehabilitation centers.” But he did describe them, with tears and encouraging claps from the audience. He talked of being caned and hit with baseball bats. “I had ping pong balls on my head” he said referringto the swellings caused by the beatings. “And when I was in pain and going through cold turkey, I was made to perform oral sex by the guards” Jaa concluded that the situation was changing for the better in Malaysia but the strict policy of incarcerating drug users, and the command and control approach to rehabilitation did not serve to encourage or develop him in anyway whatsoever. All it did was to break him down.

Jaa, as heard by delegates to the International Conference on the Reduction of Drug Related Harm in Bangkok, Thailand in 2009