December 9, 2008

I. Executive Summary

Nobody cares what happens to drug users. We have no human rights. We have no hope.
- Liu, HIV-positive former drug user, Nanning

Although drug use is illegal in China, it is considered a violation of administrative law, which states that "drug takers must be rehabilitated." Historically, this "rehabilitation" has taken the form of the extended confinement of drug users in detoxification or re-education through labor (RTL) centers, which Chinese law requires to provide psychological and medical therapy for drug dependency. In practice, these centers provide little or no therapy and, rather than being treated as patients, drug users are treated as criminals and subject to physical, psychological, and sexual abuse; forced labor; and inhumane living conditions.

In the past five years, attention to drug users and the provision of effective drug dependency treatment, has begun to change. China has won increasing praise for its aggressive response to the HIV/AIDS epidemic. Among other efforts, the Chinese government has sharply expanded HIV prevention programs and increased the availability of "first line" HIV treatment medicines. Particularly promising have been community-based programs targeting drug users that have increased the availability of methadone therapy to address opioid drug dependency. Yet, despite these advances, harsh law enforcement practices and extended confinement of drug users in detox and RTL centers continue, impeding efforts to provide effective drug dependency therapy and ignoring the HIV prevention and treatment needs of drug users.

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At the time of the founding of the People's Republic of China in 1949, it is estimated that 20 million Chinese used opium. Among its first acts in power, the new communist government launched a series of steps to combat widespread opium use, carrying out a nation-wide antidrug campaign that included the execution of those involved in the cultivation, manufacture, or sale of opium and compulsory "treatment" (consisting largely of enforced abstinence) and vocational "training" (involving forced labor) for opium users.

Following this campaign, during a period of more than 20 years when China was isolated politically and economically from the West, illicit narcotics were virtually unobtainable. In the 1980s, however, as Chinese economic development accelerated and China began to open its borders, large quantities of opium and heroin once again entered China and widespread drug use reemerged.

In 1990, China had 70,000 registered drug users. By 2005, 1.16 million people were registered, with estimates that the actual number of drug users was more than three million. The Chinese government's 2004 application to the Global Fund against HIV, TB and Malaria estimated that the total number of drug users was between five and six million.

Over the past decade, Chinese anti-narcotics policy has returned to post-independence approaches of executing drug traffickers and sentencing drug users to mandatory treatment and forced labor in detoxification or re-education through labor (RTL) centers. Confinement in detox and RTL centers represent the most common forms of treatment for drug dependency in China, and drug users face increasingly severe sentences for drug possession or use.  These sentences are imposed administratively, with little recourse to the courts or fundamental due process rights. While the detention is ostensibly for drug dependency treatment, rarely, in fact, is any medical or psycho-social therapy available. Upon release, few community services are available to drug users; relapse immediately following detention is common.

According to official statistics, as of 2007 there were approximately 700,000 people in China with HIV/AIDS, 260,000 of them drug users. Nearly half of all new infections in 2007 were associated with injection drug use,  and HIV prevalence in IDUs from Yunnan, Xinjiang, Sichuan, Guangxi, Guangdong, and Ningxia provinces is estimated to be over 10 percent; in some areas estimates are as high as 80 percent.

While the Chinese government's anti-narcotics policies have become more repressive over the past decade, the role of injection drug use in the spread of HIV in China has paradoxically resulted in the emergence of additional funding and increased attention to public health based approaches to drug addiction.  In the past few years the Chinese government has announced dramatic programs to address drug addiction and HIV, including the expansion of methadone maintenance therapy and commitments to expand HIV prevention education targeting drug users.China's 1998-2010 Strategic Plan included specific goals to expand programs targeting drug users both in community settings and in detox and RTL centers. China's response to HIV is now frequently described as pragmatic and even bold.

This report examines the paradox posed by current Chinese government policies, which combine expanded HIV programs targeting IDUs and increasingly repressive anti-narcotics policy. It looks specifically at the experience of IDUs accessing HIV and drug dependency services in the community and when detained in detoxification and RTL centers, and the perspectives of government and non-governmental organization officials providing services to drug users.

Human Rights Watch conducted field research in China's southern Guangxi province and in Beijing for five weeks in July-August 2007. A researcher conducted 20 interviews with Chinese Center for Disease Control (CDC) officials, provincial and city health officials, domestic and international non-government organization (NGO) workers providing healthcare and outreach services to IDUs, a physician at a detoxification center, a former RTL guard, and health workers at methadone and AIDS clinics. In addition, nineteen IDUs who had recently been detained in detoxification or RTL centers were interviewed in the cities of Nanning and Baise in Guangxi province. This on-site research was supplemented with review of relevant Chinese HIV and anti-narcotics policies and legislation through November 2008.

Our research found that IDUs in Guangxi province face a wide range of human rights abuses in the community and when confined in detox and RTL centers, increasing their risk of becoming HIV infected and impeding their access to effective HIV or drug dependency treatment. Stigma and discrimination toward IDUs, resulting in social marginalization and discrimination in employment, are compounded by an absence of legal recourse or access to treatment services.

Rights abuses documented in this report include:

·Arbitrary arrest of suspected drug users. Individuals reported that they were picked up off the street and arrested based on "resembling drug users" or past contact with police. Drug users were detained when accessing or leaving HIV prevention, testing or treatment centers.

·Arbitrary detention without due process protections. Individuals reported that they could be administratively sentenced to a detoxification or RTL center or a for up to three years with no clear procedures and no means of challenging the sentence.

·Mandatory testing without disclosure for HIV infection while detained in detox or RTL centers. Every formerly detained drug user interviewed reported being forced to undergo HIV testing while in confinement and none reported being told the result.

·Withholding or termination of HIV and drug dependency treatment to detainees confined in detox and RTL centers. HIV- positive former detainees reported the interruption of treatment, combined with little to no medical services and no care for opportunistic infections. No drug users interviewed reported access to opiate substitution therapy, including during acute withdrawal from heroin use. No drug users reported the availability of psychological or peer counseling for drug dependency.

·Physical abuse of drug users by guards at detox and RTL centers. Accounts from formerly detained drug users and from a former RTL guard indicate that physical abuse by guards is widespread at detox and RTL centers.

·Unpaid forced labor. Formerly detained drug users, including those who were critically ill, reported that they were forced to work grueling hours for no pay.

Because we limited the geographical scope of our investigation to conditions in Guangxi province, we cannot conclude that our findings are indicative of conditions throughout China.  However, the human rights abuses we document are grounded in and stem from national laws and policies that need to be addressed to ensure that the human rights of IDUs throughout the country are protected.

China has a responsibility to respect, protect, and fulfill, the rights of all persons within its jurisdiction in accordance with international human rights law.  The Chinese government's treatment of illicit drug users, including those who are HIV positive, violates China's obligations under international law.  These are derived from the international human rights treaties that China has ratified or signed, including the International Covenant on Economic, Social and Cultural Rights (ICESCR),the International Covenant on Civil and Political Rights (ICCPR), and the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment of Punishment.

China is obliged to respect the right of everyone to "the enjoyment of the highest attainable standard of physical and mental health." Respect for the right to health also incorporates respect for other rights such as the right to privacy and the right to seek, receive, and impart information.  With respect to the right to health of persons in custody, international standards provide that prisoners (and non-prisoners, such as drug users confined for treatment) are entitled to a standard of health care equivalent to that available in the general community, without discrimination based on their legal status.

China is also obliged to provide protection for all persons from arbitrary arrest and detention, ensure humane conditions of detention, and meet international fair trial standards. China's compulsory detoxification and re-education through labor centers violate international prohibitions on the use of unpaid forced labor.

Beyond international human rights law concerns, Chinese law requires that all patients in compulsory rehabilitation centers be provided with "medical and psychological treatment, legal education, and moral education." Yet this law is blatantly disregarded. Drug users in rehabilitation centers are treated as prisoners, not patients, and subject to abusive and inhumane conditions of confinement.

To effectively achieve its HIV goals, the Chinese government recognized that it had to expand community-based services to drug users and that these services had to include outreach, peer education, and opiate substitution therapy (such as methadone) to address drug dependency. These pragmatic efforts will fail unless anti-narcotics policies and police practices are also reformed to recognize the rights of drug users and eliminate the mandatory detention of drug users for "rehabilitation." Otherwise, the result will be missed HIV goals, continued high rates of drug dependency, and needless death.