Re: Ethical Concerns in Xue Y-X et al. A Memory Retrieval-Extinction Procedure to Prevent Drug Craving and Relapse. Science. 2012.
To the Editors:
In a recent issue of Science, Yan-Xue Xue et al. report on experiments conducted on rats and drug users examining memory retrieval and extinction to prevent drug craving and relapse in Beijing, China.[i] While the authors state that the study participants gave written informed consent, and that the research was approved by the Human Investigation Committee of the Peking University Health Center, significant question about ethical protections remain.
First, the authors’ description of the drug users participating in the study is incomplete. They state that “participants in the human study were 66 formerly heroin-dependent male inpatients at the treatment centers of Beijing Ankang and Tian-Tang-He Drug Rehabilitation Center”. What they don’t mention is that Beijing Ankang and Tiantanghe are compulsory treatment centers run by the Beijing Municipal Public Security Bureau and the Beijing Municipal Bureau of Justice (respectively) housing people detained without due process. Over the past few years, Chinese compulsory treatment centers have also begun accepting voluntary patients. The specific dates the research was conducted and whether the study participants in Xue et al.’s paper were voluntary patients or were being held under administrative detention are not clear from the article, nor is the standard of drug dependency treatment provided in either center.
According to a 2010 article in China Daily, drug users arrested by the police typically spend two years at the Beijing Ankang drug detention center, engaged in “therapies” such as boxing, art, sand-play therapy and “traversing rope and chain bridges”.[ii] The center is staffed, according to the article, by 20 psychologists “working at the center alongside 30 policemen.” An older news article from 2004 described forced labor at the center: “new arrivals start on the cleaning team in a hierarchical working structure. Good performance, upbeat spirit and a positive attitude to help others will lead them to the higher level -- the catering team, the administration team and eventually the stimulation team.”[iii]
Less information is available about the Tiantanghe compulsory rehabilitation center, however another China Daily article, from 2009, reported that “patients are asked to live in quarantine”, and showed photos from the first public opening of the center of a policewoman teaching yoga, and of detainees hitting and kicking “gas-filled dummies to relieve pressure during a treatment process”.[iv] None of these approaches can be considered evidence-based or best practices in drug dependency treatment.
Since 2005, Human Rights Watch has conducted a series of investigations into access to HIV prevention and treatment for IDU in China,[v] as well as conditions in compulsory drug detention centers.[vi]Our research has found a wide range of severe human rights abuses in so-called drug treatment or rehabilitation centers, including: denial of due process protections such as legal representation, judicial oversight or the right to appeal; mandatory HIV testing (without being told the result); physical and sexual abuse; forced labor; and the denial of health care, including effective, evidence-based drug dependency treatment. Other researchers have also reported on the abuse of drug users in detention centers, including research involving the use of electric shocks while detainees viewed pictures of drug use.[vii]
These abuses violate international human rights law, including the right to freedom from torture and cruel, inhuman and degrading treatment; the right to freedom from arbitrary arrest and detention; the right to a fair trial; the right to privacy; the right to the highest attainable standard of health and to be free from forced labor.[viii] Recognition of these abuses has led to international calls for the closure of compulsory drug detention centers, including by the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria,[ix]and in a recent joint letter by 12 UN agencies.[x]
In response to a 2011 Human Rights Watch report on drug detention centers in Vietnam that found similar conditions to what we have previously reported in China,[xi] the heads of the US National Institute for Drug Abuse (NIDA) and the White House Office of National Drug Control Policy wrote that: “agents who would routinely and without due process force drug users to undergo “treatment” and “rehabilitation” in the conditions described in your report not only would violate NIDA’s principles of drug treatment, but also would infringe upon internationally recognized human rights.”[xii] Two of the authors on the research paper, are from NIDA, and the preparation of the manuscript was financially supported by NIDA, making it all the more important that the ethical questions involved in such research be answered.
Research in compulsory drug detention centers that operate outside of judicial oversight deserve strict scrutiny. The authors state that “During the study, all participants remained hospitalized and received their usual drug-free rehabilitation treatment.” However, the authors do not explain what the “usual” treatment provided to individuals in the drug detention centers was or the average length of detention in the two centers (beyond the study’s requirement that participants be opiate-free for at least one month prior to the study, an inclusion criterion, and remain for six additional months). If, as has been previously reported, the “usual” treatment is unproven and non-evidence-based care, the study authors should discuss the ethical implications of studying heroin craving on individuals not receiving the best standard of care during a prolonged period of detention. Further, in labeling the participants as “patients” and the detention center as a “hospital”, the authors risk legitimatizing the centers, and mischaracterizing study participants and the conditions under which the research was undertaken. Regardless of the possible ability of individuals to freely consent to participate in research, the first obligation of a researcher should be to appropriately investigate and characterize the setting of the research.
NIDA and Science Magazine should investigate the ethical manner in which the study was conducted and ensure that drug users in compulsory detention settings, already victims of human rights abuses, are not also abused by unethical research.
Joseph J. Amon, PhD, MSPH
Health and Human Rights Division
Human Rights Watch
New York, NY
Dr. Nora Volkow
National institute of Drug Abuse
[i]Y.X. Xue et al. A Memory Retrieval-Extinction Procedure to Prevent Drug Craving and Relapse. Science. 336, 241-245 (2012).
[ii]Z. Yan. New approach at drug rehab center. China Daily. Mach 10, 2010. http://www.chinadaily.com.cn/metro/2010-03/10/content_9566293.htm(accessed April 17, 2012).
[iv]China Daily. Rehab center opens to public in Beijing. http://english.sina.com/china/p/2009/0415/234278.html(accessed April 17, 2012)
[v]Human Rights Watch. Restrictions on AIDS Activists in China. New York: Human Rights Watch, 2005.
[vi]Human Rights Watch. An unbreakable cycle: drug dependency treatment, mandatory confinement, and HIV/AIDS in China’s Guangxi Province. New York: Human Rights Watch; 2008.
[vii]D. Wolfe. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 18, 246-254 (2007).
[viii]D. Wolfe D, J. Cohen. Human rights and HIV prevention, treatment, and care for people who inject drugs: key principles and research needs. J Acquir Immune Defic Syndr. 1(55)Supplement1:S56-62 (2010).
[ix]Remarks by Global Fund Director Michel Kazatchkine at the International AIDS Conference in Vienna, Austria. Global Fund: Providing Impact, Promoting Rights. The Global Fund to Fight AIDS, Tuberculosis and Malaria, July 21, 2010. Available at: http://www.theglobalfund.org/documents/ed/remarks_iac_proving_impact_promoting_right_100721.pdf(accessed April 17, 2012)
[x]United Nations. Joint Statement: Compulsory drug detention and rehabilitation centres. http://www.unaids.org/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint%20Statement6March12FINAL_en.pdf (accessed April 17, 2012).
[xi]Human Rights Watch. The Rehab Archipelago: Forced Labor and Other Abuses in Drug Detention Centers in Southern Vietnam. New York: Human Rights Watch; 2011.
[xii]Letter from R. Gil Kerlikowske and Nora Volkow. Executive Office of the President. Office of National Drug Policy http://www.whitehouse.gov/sites/default/files/ondcp/Blog/ondcp_nida_letter.pdf(accessed April 17, 2012).