In the name of treatment: ending abuses in compulsory drug detention centers

In some Asian countries people who use illicit drugs and those suspected of drug use are detained involuntarily for long periods in ‘drug treatment centers’ that do not provide evidence-based drug treatment and regularly commit human rights abuses. Researchers and health professionals should advocate for the closure of these centers. In some Asian countries—including Burma, Cambodia, China, Laos, Malaysia, Thailand and Vietnam—people who use illicit drugs or those suspected of drug use can be detained involuntarily for long periods for the ostensible purpose of treatment of drug dependence [1]. ‘Drug treatment centers’ are generally run by the police and, if they provide treatment at all, do not provide services that correspond to recognized good practices. Recent reports have brought to light a wide range of human rights abuses committed in these centers in the name of treatment [2–6]. It is urgent that the ‘treatment’ façade of these institutions be denounced and that researchers and health professionals join human rights advocates in advocating for the closure of these centers. ‘Drug treatment centers’ are better referred to as compulsory drug detention centers. People may be put into such centers without being properly charged or brought before a court or tribunal to answer charges or challenge the sentence of detention, as should happen in criminal proceedings [2–5]. Police crackdowns may swell the population of these centers. People have been detained based on one positive drug test and, in some places, even people who have no history of drug use have been detained [3]. In some cases people may be brought into the centers by family members made desperate by the absence of affordable treatment options. While practices in compulsory drug ‘treatment’ centers are largely shrouded in secrecy, the few investigative reports available underscore that ‘treatment’ is a cruel misnomer. Military-style drills and forced labor are more likely to be the order of the day than health-care activities [2–4,6]. Some centers have no trained health professionals as regular staff members. Not only is good-quality treatment largely absent, but human rights organizations have documented cruel, inhuman and degrading practices equivalent to torture in these centers. These include sexual assault, slave-like conditions of hard labor, severe beatings and caning, forced testing for human immunodeficiency virus (HIV) and other sexually transmitted diseases without test results or treatment being made available, electric shocks and grossly inadequate food and sanitation [3–5]. Reports of inhumane conditions in the centers inspired the former United Nations Special Rapporteur on Torture to assert that ‘it is clear that abuses—sometimes amounting to torture—are commonplace in drug treatment centers, both public and private’[7]. In the countries where compulsory drug detention is practised, heroin is widely consumed. Some of these countries—notably China, Malaysia and Vietnam—have successfully established opioid maintenance therapy (with methadone or buprenorphine) as part of HIV control programmes [2,8]; yet reports from all these countries indicate that the number of people being detained without due process in compulsory detention centers far exceeds those admitted to out-patient methadone therapy. The World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) in 2010 issued a set of principles meant to suggest international standards for the treatment of drug dependence [9]. These standards, long in coming, assert that compulsory detention related to treatment of drug dependence should be restricted to instances where less repressive measures have been exhausted, where the patient presents a potential danger to himself or others, and for very limited periods. Plainly, these principles are violated in compulsory drug detention centers. A 2010 UNODC discussion paper characterizes compulsory drug detention centers as: ‘in reality a type of low-security imprisonment’[10]. This characterization misses an important distinction. Prisons are legitimate institutions in criminal justice systems. In functioning justice systems, people are sentenced to prison after a judicial proceeding, usually with the right to appeal a verdict or sentence. Drug detention centers, by contrast, do not serve legitimate criminal justice objectives or social objectives. Cheap labor provided by detainees may serve the economic interest of profiteers [4], but it does not justify the abuses of human rights and medical ethics entrenched in these centers. UNODC and the Global Fund to Fight AIDS, Tuberculosis and Malaria have supported training programs for drug detention centre staff in Vietnam [4], and Global Fund grants have supported HIV treatment in some centers in Vietnam and China. Recognizing an ethical quandary, Dr Michel Kazatchkine, the Global Fund executive director, called publicly for the closure of these centers but noted that the Fund would not exclude funding ‘evidence-based HIV prevention and treatment’ in the centers until they are closed, particularly in cases where detainees would otherwise be deprived of these services [11]. Research in drug detention centers similarly raises ethical dilemmas. It is doubtful that informed consent to participate in research can be truly obtained in settings where people consistently fear arbitrary use of force and deprivation of all kinds. Researchers should be wary of undertaking any work that would lend legitimacy to these institutions. In May 2011, the World Medical Association (WMA) called for the closure of compulsory drug detention centers wherever they exist. Citing forced labor and other abuses that are rife in these centers, WMA asserted that closing the centers is consistent with the principle that ‘drug therapy should be administered according to professional guidelines and supervised by specially trained physicians’[12]. While some heads or other representatives of United Nations agencies have expressed concerns about the centers, to our knowledge there has not been a public call for closure of the centers from these agencies or a policy statement endorsed by their governing bodies. A November 2011 news report indicated that the Russian Duma is considering legislation to enable widespread use of compulsory detention for treatment purposes [13]. Giving legal grounding to this practice in any country would be a terrible injustice. There is an urgent need for national medical associations and other entities speaking for health professionals to follow the WMA lead and advocate for the closure of compulsory drug detention centers. Health professionals should push the World Health Organization, UNODC and other UN agencies to be bold advocates for closure. Ending crimes committed in the name of drug treatment should be an urgent public health priority. No conflict of interest.