October 11, 2011

III. Donors: The Way Forward

Involuntary detention in compulsory centres for drug users is common in Asia. Treatment should always be voluntary and provided only with the consent of the drug user, and not, as frequently happens in the Asia region, either when arrested by the police or solely at the request of the user’s family.
—World Health Organization, “Technical Briefs on amphetamine-type stimulants,” 2011[146]

Centers like Somsanga are not unique to Lao PDR. In recent years, UN agencies and international organizations have begun to express concern about drug detention centers in various countries in Asia.

 In a plenary address in July 2010 at the 18th International AIDS Conference (held in Vienna, Austria) the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria Dr. Michel Kazatchkine, called for the closure of all compulsory drug detention centers.[147] The Joint UN Programme on HIV/AIDS (UNAIDS) has called for “the earliest possible closure of such centers.”[148] UNDP, UNICEF, and the UN high commissioner for human rights have also criticized the centers.[149] The UN special rapporteurs on torture and health have also spoken out against abuses in drug detention centers. In 2010, the director of the Drug Policy Coordination Unit of the European Commission deemed such centers an “abomination.”[150]

The World Medical Association (WMA) and the International Federation of Health and Human Rights Organizations (IFHHRO) have called for the closure of such centers, on the grounds they violate the human rights of the detained and operate without following accepted principles of medical treatment.[151]

Such positions have been replicated by UN agencies and embassies at the country-level. The UN country team in Vietnam has stated that it “does not support” the use of detention centers for drug users.[152] The UN country team in Cambodia has stated that “there is no reason for the centers to remain open.”[153] The US Embassy in Vietnam has pressed the Vietnamese government for “elimination of [compulsory] drug treatment centers” in that country.[154]

For its part, UNODC has criticized the approach of routine, en masse long-term detention in the name of “treatment”:

Many countries provide long term residential treatment for drug dependence without the consent of the patient that is in reality a type of low security imprisonment. Evidence of the therapeutic effect of this approach is lacking, either compared to traditional imprisonment or to community-based voluntary drug treatment. It is expensive, not cost-effective, and neither benefits the individual nor the community. It does not constitute an alternative to incarceration because it is a form of incarceration. [155]

Somsanga shares the underlying operating principle of the centers criticized by these organizations. Lao authorities have developed—and international donors have continued long-term support for—a system that results in routine, en masse long-term detention in the name of “treatment.”

The underlying operating principle of Somsanga—detention of people against their will in the name of “treatment” and “rehabilitation”—violates the right to health of people dependent on drugs. Except in exceptional “crisis” situations, health interventions should only be administered on a voluntary basis following the fully informed consent of the patient. Even then, involuntary treatment can only be justified when it is in the best interests of the patient, for short periods of time to return the patient to a state of autonomy over his or her own decision making, and when it involves interventions which are medically and scientifically appropriate (which is not the case, for instance, when detention itself is the mainstay of treatment).

In December 2010, UNODC, the UNAIDS and the UN Economic and Social Commission for Asian and the Pacific (ESCAP) convened a meeting in Bangkok, Thailand, to discuss alternatives to compulsory drug detention centers in the region. Government officials from China, Vietnam, Thailand, Malaysia, Cambodia, Burma, Indonesia, and the Philippines attended the meeting.[156] Officials from Lao PDR chose not to attend and staff members of international organizations familiar with the meeting explained that this decision reflected the Lao government’s position that its centers are voluntary.[157]

Somsanga operates in clear disregard of the principles articulated by one of its principal supporters, UNODC. According to UNODC:

Treatment carried out without the informed consent of the patient in clearly defined exceptional circumstances needs to follow similar criteria to those used in mental health emergency situations. It should, for example:
        Require a clinical judgment by at least two qualified healthcare professionals that such treatment was necessary
        Impose a time limit of several days for compulsory treatment (to return the person to a state of autonomy in which decisions regarding their own welfare can be taken, maximum several days)
        Include a judicial review for any continued necessity, including the right to appeal
        Involve medically appropriate, individually prescribed plan, subject to regular review, that is consistent with international evidence-based best practice and ethical standards.[158]

Not only does the operational basis of Somsanga violate the right to health, but the human rights context of Lao PDR means that closed centers for so-called drug “treatment” and “rehabilitation” create an unacceptably high risk that other types of people deemed “undesirable” will be arbitrarily detained alongside people dependent on drugs.

Lao PDR has a dismal record on respecting, protecting and fulfilling the due process rights of its citizens. The US State Department’s 2010 human rights report noted that arbitrary arrest and detention persist in the country. It observed:

Police agents exercised wide latitude in making arrests, relying on exceptions to the requirement that warrants are necessary except to apprehend persons in the act of committing crimes or in urgent cases. Police reportedly sometimes used arrest as a means to intimidate persons or extract bribes…. A militia in urban and rural areas, operating under the aegis of the armed forces, shared responsibility for maintaining public order and reported “undesirable elements” to police.[159]

Compounding these concerns is the Lao government’s refusal to respect the right to freedom of expression. The government owns and controls most local print and electronic media and forbids public criticism that it considers harmful to its reputation. The US State Department’s 2010 human rights report also notes the absence of independent monitoring of detention conditions.[160] This context renders the independent and transparent monitoring and reporting of the human rights conditions of detainees in centers such as Somsanga virtually impossible.

Despite the poor human rights record of Lao PDR, a UN agency, donors and international organizations have financed and supported drug dependency services that require people to be locked up for many months in closed centers. As noted above, in some instances donors have financed the actual construction and refurbishment of such closed centers, including fences.

Donor support for closed centers in a country where due process rights are routinely violated, and where public criticism of government policy is not tolerated, creates an unacceptably high risk that such closed centers will be abusive. This is what has occurred in Somsanga.

In effect, Somsanga functions as a detention center for people who use drugs (regardless of whether actually dependent), as well as a wide-range of other socially “undesirable” groups, outside of any form of due process or legal oversight.

None of the persons whom Human Rights Watch interviewed for this report had seen a lawyer or been sent to a court prior to their detention in Somsanga. There does not appear to be any means to review or appeal detention. Human Rights Watch believes that the appropriate response to the detention of people against their will and without due process is their immediate release from such arbitrary detention. The continued detention of detainees at Somsanga cannot be justified on either legal or health grounds.

There is no doubt that effective management and treatment of drug dependence in resource-poor settings (such as Lao PDR) present serious challenges. This is particularly the case of treatment services for amphetamine-type stimulants—the most common types of illegal drugs in Lao PDR—for which no form of accepted substitution therapy currently exists.

But this fact should not be used by donors as an excuse to turn a blind eye to the ongoing confinement for an indefinite period of time of hundreds of people for whom detention is arbitrary and abusive. All people, including those who are genuinely dependent on drugs, enjoy the right to freedom from arbitrary detention. Human Rights Watch believes that, given the ongoing ill treatment and suicides in Somsanga, it is safer and healthier for people, including those who are genuinely dependent on drugs, to reside in the community rather than be confined in an abusive setting.

Neither Lao PDR nor international donors should ignore human rights concerns in the provision of drug treatment, including ATS (amphetamine type stimulants) treatment. As WHO has noted:

All approaches to the treatment of ATS use should comply with human rights obligations. The human rights of people with ATS dependence must never be compromised…. Inhuman or degrading practices and punishment should never be part of the treatment for ATS dependence. All drug treatment should therefore be voluntary. Only in an exceptional crisis situation such as high risk to self or others should compulsory treatment be considered, and only as a last resort.[161]

For some people dependent on drugs (as well as many others who are poor, homeless, infrequent drug users or beggars), vocational training courses may be beneficial. But access to such services should be conditional on months of involuntary detention in closed centers.

The way forward for drug dependence services in Lao PDR should begin with an affirmation of the human rights principle of the availability of drug dependency services on a voluntary basis, following fully informed consent. WHO and UNODC note that:

[T]he same standards of ethical treatment should apply to the treatment of drug dependence as other health care conditions. These include the right to autonomy, and self determination on the part of the patient, and the obligation for beneficence and non maleficence [do good/do no harm] on behalf of treating staff.[162]

The principle of treatment following fully informed consent requires the establishment of a continuum of medically and scientifically appropriate services for people who use drugs.

In this respect, it should be noted that in general only a minority of people who use ATS become dependent.[163] For those who are clinically dependent, WHO considers that a range of psychosocial interventions, from cognitive behavioral therapy, contingency management and 12-step programs, have yielded encouraging results in the treatment of dependence to amphetamine type stimulants.[164] Human Rights Watch is not aware that any of these interventions are available in Lao PDR.

According to one staff member of an international organization who is familiar with drug issues in Lao PDR:

To my knowledge there are only very limited voluntary services for drug users in Vientiane, and none for amphetamine users. Drug use is still seen by the authorities as requiring punishment, as opposed to medical and social support. Moving forward, there's a need to set up community treatment options for drug users. Such community services would certainly be closer to the Lao culture of compassion [than Somsanga].[165]

Specialized residential treatment facilities—in which people are able to come and go, and are offered medically and scientifically appropriate services—should be available for some heavily dependent drug users. Human Rights Watch believes that a key condition of specialized residential facilities for drug treatment should be their voluntary nature.

Specialized residential treatment facilities operating in Lao PDR would require basic human rights safeguards, such as admission mechanisms to ensure admissions are truly voluntary (and not susceptible to abuse by families, police, or local militia). In cases where persons are admitted to the residential facility on the basis of a decision to detain the individual, there should be due process protections (including legal representation and the right to appeal) to ensure that such decisions are only taken in the patient’s best interests, are time limited and are subject to appeal. Equally importantly, specialized residential treatment facilities would require rigorous independent monitoring and reporting—including confidential interviews of both current patients and those recently discharged—as well as public reporting on conditions inside the centers.

These conditions are not present at Somsanga and continuing donor support for the Somsanga center has an unacceptably high risk of engendering the types of human rights abuses that this report has documented.

Before international donors continue funding Somsanga under the mistaken belief that it is a “reformed” detention facility now operating as a specialized residential treatment facility, they should assess this approach in terms of the actual and potential human rights violations associated with it. In addition to violating the right to health of people who use drugs, that assessment should acknowledge arbitrary detention in Somsanga, the risk of exposure to cruel, inhuman, and degrading treatment or punishment that detention entails, as well as the recognition that such abuses will very likely persist in a country noted for its dismal record regarding respecting due process rights and intolerance of public criticism.

In many countries, NGOs offer the range of health services required to provide drug dependence services. Historically, government authorities in Lao PDR have suppressed NGOs. A Decree on Associations, issued by the prime minister in 2009, has the potential to allow for a range of technical and social-welfare oriented NGOs.[166]

According to accounts of staff members of organizations familiar with drug issues in Lao PDR, applications for registering NGOs have been painfully slow. But support by donors for NGOs has the potential to provide needed services for people who use drugs (and other socially marginalized groups) without the human rights risks inherent in closed centers. Donors should fund medically and scientifically appropriate healthcare interventions which are available via voluntary, community-based services.

[146] World Health Organization, “Technical Briefs on amphetamine-type stimulants (ATS): Principles of prevention and treatment for the use of amphetamine-type stimulants (ATS),” undated. www.wpro.who.int/sites/hsi/documents/atstechnicalbriefs.htm (accessed June 8, 2011).

[147] “Providing Impact, Promoting Rights. The Global Fund to Fight AIDS, Tuberculosis and Malaria,” Michel Kazatchkine, presentation at AIDS 2010 - XVIII International AIDS Conference, July 18-23, 2010, http://www.theglobalfund.org/documents/ed/remarks_iac_proving_impact_promoting_right_100721.pdf

[148] Letter from Michel Sidibé, Executive Director of UNAIDS to Human Rights Watch, March 30, 2010, on file with Human Rights Watch

[149]Comments by Mandeep Dhaliwal, Cluster Leader: Human Rights, Gender & Sexual Diversities, United Nations Development Programme, “Harm Reduction 2010 The Next Generation: Addressing the Development Dimensions,” presentation at the International Harm Reduction Association Annual Conference, Liverpool, April 29, 2010; “Statement of the care and protection of children in institutions in Cambodia,” UNICEF East Asia & Pacific Regional Office, June 8, 2010, http://www.unicef.org/eapro/UNICEF_Statement_on_HRW.pdf (accessed May 12, 2011); Email from Gottfried Hirnschall, Director of HIV/AIDS Department of WHO to Human Rights Watch, May 6, 2010, on file with Human Rights Watch; “High Commissioner calls for focus on human rights and harm reduction in international drug policy,” United Nations Office of the High Commissioner on Human Rights press release, March 10, 2009, http://www.unhchr.ch/huricane/huricane.nsf/view01/3A5B668A4EE1BBC2C12575750055262E?opendocument (accessed May 12, 2011).

[150] UN Human Rights Council, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Manfred Nowak, A/HRC/10/44, January 14, 2009, http://www2.ohchr.org/english/bodies/hrcouncil/docs/10session/A.HRC.10.44AEV.pdf (accessed May 12, 2011); UN General Assembly, Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover, A/65/255, August 5, 2010, http://daccess-ods.un.org/TMP/1360889.82224464.html accessed May 12, 2010); Comments by Carel Edwards, Director of the Drug Policy Coordination Unit of the European Commission, in Hungarian Civil Liberties Union, “Abuse in the Name of Treatment- Drug Detention Centers in Asia,” video report, 2010, http://tasz.hu/en/hclu-film/abuse-name-treatment-drug-detention-centers-asia (accessed May 12, 2011).

[151] “Call for Compulsory drug detention centers to be closed,” World Medical Association and International Federation of Health and Human Rights Organizations press release, May 17, 2011, http://www.ifhhro.org/news-a-events/225-world-medical-association-a-ifhhro-joint-press-release (accessed September 5, 2011).

[152] United Nations in Vietnam, “Position on Administrative Detention for Sex Workers and People Who Use Drugs,” August 2010, para 5. http://www.unaids.org.vn/sitee/images/stories/newsroom/2011/un_position_paper_on_administrative_detention_15_august_2011.pdf (accessed September 9, 2011. For an analysis of the human rights conditions in drug detention centers in Vietnam, see Human Rights Watch, The Rehab Archipelago: Forced labor and Other Abuses in Drug Detention Centers in Southern Vietnam, September 2011. http://www.hrw.org/reports/2011/09/07/rehab-archipelago-0

[153] United Nations in Cambodia, “UN Common Viewpoint: Support to the Royal Government of Cambodia to deliver evidence-based Drug Dependence Detoxification, Treatment and Aftercare for people who use drugs,” May 2010, para. 2. http://www.unodc.org/documents/eastasiaandpacific/cambodia/UNCT_Common_Viewpoint_on_Drug_Dep_Treatment_June_2010_FINAL.pdf (accessed September 28, 2011). For an analysis of the human rights conditions in drug detention centers in Cambodia, see Human Rights Watch, “Skin on the Cable”: The Illegal Arrest, Arbitrary Detention and Torture of People Who Use Drugs in Cambodia, January 2010. http://www.hrw.org/reports/2010/01/25/skin-cable-0

[154]Letter to Human Rights Watch from Gregory Beck, deputy assistance administrator, bureau for Asia, United States Agency for International Development, September 14, 2011.

[155]UNODC, “From Coercion to Cohesion: Treating drug dependence through healthcare, not punishment,” March 2, 2010, p. 11. See also UN Commission on Narcotics Drugs, “Drug Control, Crime Prevention, and Criminal Justice: A Human Rights Perspective, Note by the Executive Director,” E/CN.7/2010/CRP.6*–E/CN.15/2010/CRP.1 , March 3, 2010, http://www.unodc.org/documents/commissions/CND-Uploads/CND-53-RelatedFiles/ECN152010_CRP1-6eV1051605.pdf (accessed May 12, 2011).

[156] See UN Economic and Social Commission for Asia and the Pacific, “Regional Consultation for Compulsory Centers for Drug Users (CCDUs) in Asia and the Pacific: 14 to 16 December 2010, Bangkok,” undated, http://www.unescap.org/sdd/meetings/CCDU-Nov2010/index.asp (accessed September 27, 2011).

[157] Human Rights Watch interview with two staff members of two international organizations, September 2011.

[158] UNODC, “From Coercion to Cohesion: Treating drug dependence through healthcare, not punishment,” March 2, 2010, p. 11.

[159] US State Department, Bureau of Democracy, Human Rights, and Labor, “Country Reports on Human Rights Practices – 2010: Laos,” April 8, 2011, http://www.state.gov/g/drl/rls/hrrpt/2010/eap/154390.htm (accessed June 6, 2011).

[160] Ibid.

[161]World Health Organization, “Technical Briefs on amphetamine-type stimulants (ATS): Principles of prevention and treatment for the use of amphetamine-type stimulants (ATS),” undated, www.wpro.who.int/sites/hsi/documents/atstechnicalbriefs.htm (accessed June 8, 2011).

[162] UNODC/WHO, “Principles of Drug Dependence Treatment,” p. 9.

[163] World Health Organization, “Technical Briefs on amphetamine-type stimulants (ATS): Principles of prevention and treatment for the use of amphetamine-type stimulants (ATS),” undated. www.wpro.who.int/sites/hsi/documents/atstechnicalbriefs.htm (accessed June 8, 2011). One study of lifetime psycho=stimulant users found that 11.2 percent developed drug dependence (as defined by the International Classification of Diseases (ICD)-10): Anthony JC et al. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 1994, vol. 2(3), pp. 244–268, p. 255.

[164] World Health Organization Western Pacific Region, “Technical Briefs on amphetamine-type stimulants (ATS): Therapeutic interventions for users of amphetamine-type stimulants,” undated. www.wpro.who.int/sites/hsi/documents/atstechnicalbriefs.htm (accessed June 8, 2011).

[165] Human Rights Watch interview with staff member of an international organization, September 2011.

[166]See Lao People’s Democratic Republic, Decree on Associations, No. 115/PM, April 29, 2009.