INTERNATIONAL FEATURE Harm reduction and drug policy in ASEAN: an uneasy but critical partnership for health and human rightsadmin
INTERNATIONAL FEATURE Harm reduction and drug policy in ASEAN: an uneasy but critical partnership for health and human rights
HIV Australia | Vol. 14 No. 1 | March 2016
By Gloria Lai
At a high-level meeting of Association of Southeast Asian Nations (ASEAN) countries, held in Malaysia in October 20151, ministers yet again reiterated their commitment to rid the region of drugs:
‘While some drug-related support services may be implemented, ASEAN is committed to a zero-tolerance approach to realise its regional vision of a Drug-Free ASEAN, so as to provide our people and communities with a society free from drug abuse and its ill-effects.’2
Consistent with ASEAN’s prior work plan on drugs, ‘some drug-related support services’ likely refers to drug use prevention and rehabilitation, while the aim of achieving ‘a society free from drug abuse’ directly contradicts the provision of harm reduction measures for people who use drugs.
ASEAN’s unwavering commitment to achieving a drug-free region has justified the brutal criminalisation and punishment of people who use drugs, along with unbalanced investment in law enforcement at the expense of health and harm reduction interventions, thereby fuelling HIV and hepatitis epidemics among people who inject drugs in the region.3 4
Over a decade after harm reduction programs were introduced in several countries throughout South East Asia, ASEAN’s drug policy makers clearly have not shifted their stance in support of them. Yet efforts to build collaboration between law enforcement, harm reduction, civil society and communities of people who use drugs have taken root in certain localities throughout the region.
In the context of global shifts away from criminalisation and punishment, such developments provide further evidence of the need for ASEAN to update their policies in response to drug use.
ASEAN’s contradictory approach to HIV and drug use
As with many other parts of the world, drugs are regarded first and foremost as a security threat to South East Asia. In its drug strategy and work plan, ASEAN portrays drug markets as a key security concern, and as a cause of individual suffering weakening ‘the social fabric of nations’, direct and indirect economic costs to governments, along with criminal activities that could threaten the stability of states.5
The 1998 Joint Declaration for a Drug-Free ASEAN outlines a broad strategy for eradicating the production, trafficking and use of controlled drugs in the region by 2020. In 2000, to highlight the urgent need to tackle expanding drug markets for use and supply, the target year for achieving a drug-free region was brought forward to 2015.6 7
Regional policy makers adopted the ASEAN Work Plan on Combating Illicit Drug Production, Trafficking and Use (2009–2015)(the Work Plan)8 to set out agreed priorities for eradicating supply through the ‘elimination’ of syndicates involved in the production and trafficking of drugs and their precursors, and for reducing the prevalence of drug use, primarily through preventative education programs.
The ASEAN Senior Officials on Drug Matters, comprising senior officials from agencies with responsibility for drug-related issues from each member state, has responsibility for coordinating, monitoring and evaluating implementation of the Work Plan.
Despite high levels of HIV prevalence among people who inject drugs throughout the region (see Table 1), there is only one mention of HIV/AIDS in the entire ASEAN Work Plan on drugs: as a component of preventative education programs for the general population and people who use drugs.
Table 1: HIV prevalence among people who inject drugs in ASEAN countries20
The Work Plan does not refer to the comprehensive package of interventions advised by the World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS ) and United Nations Office on Drugs and Crime (UNODC) to provide HIV prevention, treatment and care services for people who inject drugs, including opioid substitution therapy (OST) and needle/syringe programs (NSP) (re-affirmed and expanded upon to include overdose prevention in the Consolidated Guidelines on HIV prevention, diagnosis, treatment and care for key populationspublished by the WHO in 2014).9 10
Nor does it refer to the ASEAN Declaration of Commitment: Getting to zero new HIV infections, zero discrimination, zero AIDS-related deaths, which includes a commitment by ASEAN governments to reduce transmission of HIV among people who inject drugs by 50 per cent by 2015.11 Such commitments are critical given the high rates of HIV prevalence among people who inject drugs in ASEAN.
While several countries in ASEAN provide OST and/or NSP as key harm reduction interventions, the availability and accessibility of these critical measures throughout the region is inadequate.12 The Declaration states that ASEAN countries commit to implementing and expanding ‘risk and harm reduction programmes, where appropriate and applicable, for people who use drugs’.13
However, as mirrored at national level in most countries throughout the region, there appears to be no integration between the ASEAN entities working on respectively HIV and drug policy, despite clear recognition of the need for it by the ASEAN Task Force on AIDS.14
Given the framing of drugs as primarily a security concern, policymakers struggle with responding to the health and human rights concerns that relate to drugs. Such concerns arise from the implementation of drug policies that focus overwhelmingly on criminalisation and punishment, rather than from the use of drugs itself, as noted in a paper released by the International Drug Policy Consortium in 2013:15
- widespread human rights violations, including abusive practices by police against people who use drugs, and the use of compulsory drug detention and rehabilitation centres that have been condemned by United Nations agencies16 17 18 19
- punitive and stigmatising measures in response to drug use, including compulsory registration, criminal conviction, imprisonment and detention, and denial or inadequate provision of life-saving harm reduction measures such as OST, NSP and overdose prevention, and
- disproportionate sentences and penalties for drug-related activities, including lengthy imprisonment sentences for low-level, non-violent offences, and use of the death penalty.21 22
It is confounding that ASEAN policy makers insist on following the same drug strategies despite the extensively damaging consequences for public health and human rights.
It is even more baffling that they continue to reiterate the same objectives and approaches despite clear evidence of their failure to eliminate, or even reduce, the use and supply of drugs.
Available data on regional drug trends in the past decade show that there has been no significant reduction in the overall use and supply of drugs, but instead expanding markets, particularly for synthetic drugs such as methamphetamine.23 24
Engaging public health and law enforcement
In the lead up to the UN General Assembly Special Session on the world drug problem this year, an increasing number of countries and UN agencies have called for a shift towards a public health approach to drugs. This includes the US, which has traditionally led the global ‘war on drugs’.25
The United Nations (UN) Secretary General Ban Ki Moon has repeatedly supported the removal of criminal sanctions for people who use drugs, and called on member states to:
‘… consider alternatives to criminalization and incarceration of people who use drugs and focus criminal justice efforts to those involved in supply. We should increase the focus on public health, prevention, treatment and care, as well as on economic, social and cultural strategies.’26
Several UN agencies have also issued recommendations for the removal of criminal penalties for drug use and possession for personal use, (decriminalisation), including UNAIDS27 28, UN Development Program29, WHO30, the Office of the High Commissioner on Human Rights31, UN Women32, and the UN Special Rapporteur on the Right to Health33 34.
Similarly, the United Nations Office on Drugs and Crime stated in 2013 that people who use drugs should ‘not [be] treated as criminals’ and has called for a shift from a ‘sanction-oriented to a health-oriented approach to drug use and dependence.’35
While ASEAN governments recognise that drug policy requires a public health dimension, they have been reluctant to take decisive steps in shifting from criminalisation and punishment to health and harm reduction as their primary response to drug use.
Some countries have adopted measures that contribute towards such a shift, for example Malaysia established Cure and Care centres offering drug treatment and OST services on a voluntary basis in 201036, Thailand’s drug agency adopted harm reduction as part of its national drug strategy in 201437, and Indonesia adopted a multi-agency regulation on instituting procedures for diverting people who use drugs away from prison to rehabilitation centres in 201438.
In addition, collaboration between harm reduction services and police has been established in some jurisdictions to enable access by people who use drugs without fear of arrest, for example:
- Cambodia – a local NGO (KHANA) and the Ministry of Interior introduced the Police Community Partnership Initiative at HIV ‘hotspots’ in Phnom Penh, where police are encouraged to refer people who inject drugs to harm reduction services instead of arresting them (where there is no evidence of drug trafficking).39
- Thailand – an informal truce was negotiated between non-government health service providers and local law enforcement officers in Narathiwat Province, following a series of capacity building and sensitisation workshops. Local law enforcement officers agreed to apply greater discretion in avoiding arrest and instead, refer people who use drugs to health services.40
However, these developments supporting greater access to harm reduction measures remain tenuous, contentious, and at risk of lapsing (or worse, reversal) if they are not formally instituted with legislative and policy reforms that remove criminal and other punitive sanctions against people who use drugs.
In particular, the entrenched policy in most ASEAN countries of compulsory detention in so-called rehabilitation centres for people arrested for drug use is a significant barrier to access to harm reduction measures and must end, particularly as extensive abuse occurs at these centres.41 42 43 44 45
Governments need to invest instead in the development and provision of evidence-based health and harm reduction services, along with ensuring an enabling legal and policy environment that supports voluntary access to those services by people who use drugs.46 47
As rates of drug use continue to rise, and the availability of drugs expand, ASEAN governments must ensure that their drug policy and harm reduction responses are well-equipped for protecting the health, welfare and lives of their citizens. Such an approach is particularly critical for the development of post-2015 strategies on drug control, health and HIV (many ASEAN strategies ended in 2015, including its drug strategy).48
As governments prepare for the UN General Assembly Special Session on the world drug problem in April 2016 in New York, the hope of many civil society organisations and communities is for agreed outcomes that are relevant in managing the contemporary realities of drug markets. Glossing over the needs for drug policy reform and harm reduction interventions by recycling unrealistic drug-free strategies will not meet that expectation.
Note: the issues in this article are discussed in other publications by the International Drug Policy Consortium, including:
- Lai, G. (2015). Asia: Advocating for humane and effective drug policies, Sur International Journal on Human Rights, Issue 21, June 2015.
- International Drug Policy Consortium. (2016). A public health approach to drug use in Asia: principles and practices for decriminalisation, (in print).
1 ASEAN (Association of Southeast Asian Nations) is an intergovernmental organisation that was established in 1967 to enhance regional cooperation. It comprises 10 member states from Southeast Asia: Thailand, Malaysia, Myanmar, Indonesia, Brunei, Philippines, Cambodia, Laos, Vietnam and Singapore.
2 ASEAN. (2015, 29 October). Position statement endorsed and adopted by the 5th ASEAN ministerial meeting on drug matters, 29 October 2015, Langkawi, Malaysia. Retrieved from: www.asean.org
3 Global Commission on Drug Policy (GCDP). (2012). The war on drugs and HIV/AIDS: How the criminalisation of drug use fuels the global pandemic. GCDP, Rio de Janeiro. Retrieved from: globalcommissionondrugs.org
4 GCDP. (2013). The negative impact of the war on drugs on public health: The hidden hepatitis C epidemic. GCDP, Rio de Janeiro. Retrieved from: www.globalcommissionondrugs.org
5 ASEAN. (2015, 3 April). ASEAN Leaders’ Declaration on Drug-Free ASEAN 2015. Retrieved from: cil.nus.edu.sg
6 ASEAN. (1998, 25 July). Joint Declaration for a Drug-Free ASEAN, Manila, Philippines, 25 July 1998. ASEAN Ministerial Meeting. Retrieved from: cil.nus.edu.sg
7 ASEAN. (2000, October). Bangkok Political Declaration in Pursuit of a Drug-Free ASEAN 2015, Bangkok, Thailand, 11-13 October, 2000. Retrieved from: www.asean.org
8 ASEAN. (2009, 17 November). Joint Statement of the 7th ASEAN Ministerial Meeting on Transnational Crime (AMMTC) Siem Reap, Cambodia. Retrieved from: www.asean.org
9 World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Office on Drugs and Crime (UNODC). (2009). Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. WHO, Geneva. Retrieved from: www.unodc.org
10 WHO. (2014). Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, 29. WHO, Geneva. Retrieved from: www.who.int
11 ASEAN. (2012). ASEAN Declaration of commitment: Getting to zero new infections, zero discrimination, zero AIDS-related deaths.Retrieved from: www.asean.org
12 UNAIDS. (2013). HIV in Asia and the Pacific. UNAIDS report 2013. UNAIDS, Geneva, 17–18. Retrieved from: www.unaids.org
13 Paragraphs 16(b) and 17 (d), ASEAN. (2012). op. cit.
14 ASEAN. (2011). Statement of ASEAN Task Force on AIDS (ATFOA) in the Asia Pacific Regional Consultation on Universal Access to HIV Prevention, Treatment, Care and Support, agreed in Bangkok in 2011. Retrieved from: www.asean.org
15 International Drug Policy Consortium (IDPC). (2013). A drug-free ASEAN by 2015: harmless rhetoric or a dangerous mantra?IDPC, London. Retrieved from: idpc.net
16 United Nations. (2012, March). Joint Statement: compulsory drug detention and rehabilitation centres. Retrieved from: www.unodc.org
17 Human Rights Watch (HRW), Thai AIDS Treatment Action Group (TTAG). (2007). Deadly denial: Barriers to HIV/AIDS treatment for people who use drugs in Thailand. HRW, New York. Retrieved from: www.hrw.org
18 International Harm Reduction Development Program (IHRDP). (2009). Human rights abuses in the name of drug treatment: Reports from the field. IHRDP, New York. Retrieved from: www.soros.org
19 WHO. (2009). Assessment of compulsory treatment of people who use drugs in Cambodia, China, Malaysia and Viet Nam: an application of selected human rights principles. WHO, Geneva. Retrieved from: www.who.int
20 AIDS Data Hub. (2015). HIV and AIDS Data Hub for Asia-Pacific: Review in slides – People who inject drugs, updated in November 2015 [PowerPoint presentation]. Retrieved from: www.aidsdatahub.org
21 Global Commission on HIV and the Law (2012). HIV and the Law: Risks, Rights and Health. United Nations Development Programme (UNDP), New York. Retrieved from: www.hivlawcommission.org
22 GCDP. (2011). War on drugs. Global Commission on Drug Policy, Rio de Janeiro. www.globalcommissionondrugs.org
23 UNODC. (2015). The Challenge of Synthetics Drugs in East Asia, and South-East Asia and Oceania: Trends and Patterns of Amphetamine-Type Stimulants and New Psychoactive Substances. UNODC. Retrieved from: www.unodc.org
24 Kramer, T., Jelsma, M., Blickman, T. (2009). Withdrawal Symptoms in the Golden Triangle: A drugs market in disarray.Transnational Institute, Amsterdam. Retrieved from: www.tni.org
25 The White House. (2015, 2 February). President requests historic levels of funding for public health response to illicit drug use. Media release. Retrieved from: www.whitehouse.gov
26 Ki-Moon, B. (26 June 2015). United Nations Secretary-General Ban Ki-moon: Message on International Day Against Drug Abuse and Illicit Trafficking, UNIS/SGSM/645. United Nations, Geneva. Retrieved from: www.unis.unvienna.org
27 Joint United Nations Programme on HIV/AIDS (UNAIDS). (2015). A Public Health and Rights Approach to Drugs. UNAIDS, Geneva. Retrieved from: www.unaids.org
28 UNAIDS. (2014). The GAP report. UNAIDS, Geneva. Retrieved from: www.unaids.org
29 UNDP. (2015). Addressing the development dimensions of drug policy. UNDP, New York. Retrieved from: www.undp.org
30 WHO. (2014). op. cit.
31 United Nations High Commissioner for Human Rights. (September 2015). Study on the impact of the world drug problem on the enjoyment of human rights, A/HRC/30/65, para. 38. Retrieved from: www.ohchr.org
32 UN Women. (2014), A gender perspective on the impact of drug use, the drug trade, and drug control regimes. UN United Nations Office on Drugs and Crime (UNODC), Geneva. Retrieved from: www.unodc.org
33 United Nations (UN) General Assembly. (2010, 6 August). The Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.Report to General Assembly A/65/255. UN, Geneva. Retrieved from: www.ohchr.org
34 Report of the Special Rapporteur on torture (A/HRC/10/44). (2012). Submission to Committee on Torture 2012. UN, Geneva. www.ohchr.org
35 Rolles, S. (2015, 20 October). The truth behind the UNODC’s leaked decriminalisation paper. Transform blog. Retrieved from: www.tdpf.org.uk
36 Tanguay, P. (2011, June). Policy responses to drug issues in Malaysia. IDPC Briefing paper, 4. International Drug Policy Consortium (IDPC), London. Retrieved from: dl.dropboxusercontent.com
37 Ngammee, V., Tanguay, P. (2015). CHAMPION-IDU – Innovations, best practices and lessons learned – Implementation of the national response to HIV among people who inject drugs in Thailand 2009–2014, 14. PSI, Washington, DC. Retrieved from: www.psi.org
38 GRM International, Burnet Institute. (2014). Keeping drug users out of jail? Drug diversion policy in Indonesia. HIV Cooperation Program for Indonesia (HCPI). GRM international, Canberra. Retrieved from: www.burnet.edu.au
39 Rahman, F., Reaksmey, H., Thanh, P., Golichenko, O. (2014) . Using the heart: Law enforcement and people who use drugs in Asia, HIV Australia 12(2). AFAO, Sydney.
40 Ngammee, V. et al. (2015). op. cit.
41 Human Rights Watch (HRW). (2010). Skin on the cable: the illegal arrest, arbitrary detention and torture of people who use drugs in Cambodia. HRW, New York. Retrieved from: www.hrw.org
42 HRW. (2011). The rehab archipelago: forced labor and other abuses in drug detention centers in southern Vietnam. Human Rights Watch, New York. Retrieved from: www.hrw.org
43 HRW. (2011). Somsanga’s secrets: arbitrary detention, physical abuse and suicide inside a Lao drug detention center. Human Rights Watch, New York. Retrieved from: www.hrw.org
44 Kamarulzaman, A., McBrayer, J. (2015). Compulsory drug detention centres in South and Southeast Asia. International Journal of Drug Policy, 26, S33–37;
45 WHO. (2009). op. cit.
46 Tanguay, P., Kamarulzaman, A., Aramrattana, A., et al. (2015). Facilitating a transition from compulsory detention of people who use drugs towards voluntary community-based drug dependence treatment and support services in Asia. Harm Reduction Journal, 12, 31. Retrieved from: harmreductionjournal.biomedcentral.com
47 3rd Regional consultation on compulsory centres for drug users. (2015). Recommendations from the 3rd Regional Consultation on Compulsory Centres for Drug Users. Retrieved from: unaidsapnew.files.wordpress.com
48 IDPC. (2015). The post-2015 drug strategy for ASEAN: towards a new paradigm in drug policy? IDPC, London. Retrieved from: dl.dropboxusercontent.com
Gloria Lai is a senior policy officer for the International Drug Policy Consortium (IDPC), where she leads IDPC’s Asia regional program, based in Thailand.
She previously worked as a senior policy advisor on law enforcement and drugs, and as a lawyer for the Australian government.