<<previous  |  index  |  next>>

V. HIV/AIDS and Other Health Impacts of the War on Drugs of the War on Drugs

Whatever you do, you have to make sure you do not inadvertently drive them [drug users] underground.
—Kathleen Cravero, deputy director, UNAIDS, addressing the Thai government in March 2004

All my peers disappeared from the scene and hid themselves.  It’s not like before when you could go outside and you knew who the drug users were . . . . After the war on drugs, people disappeared because they didn’t feel safe.
—Odd Thanunchai, a peer educator and recovering heroin user in Chiang Mai

Thailand’s war on drugs not only contributed to an erosion of the country’s record on civil and political rights.  It also raised fears among health experts of a wave of HIV infection and other health complications among the country’s drug users, which include both methamphetamine users and people who inject heroin and other opiates.⁵⁵  These actions included coercing drug users into treatment and rehabilitation through threats of arrest or death; creating a climate of fear that drove drug users into hiding and away from health services, including HIV prevention services; penalizing drug users for possession of sterile syringes, resulting in an increased risk of syringe sharing and infection with blood-borne viruses; and incarcerating drug users in detention environments that posed a disproportionately high risk of disease transmission.  Human Rights Watch documented recent cases of all of these government actions.

Background on HIV/AIDS and injection drug use in Thailand

Despite the epidemic levels of methamphetamine use in Thailand, an estimated 100,000-250,000 of the country’s drug users still inject heroin.⁵⁶  Heroin first appeared in Thailand after the government banned the smoking of opium in 1959.⁵⁷  Though initially confined to inhaling, the heroin epidemic soon shifted to injection drug use and, by the mid-1980s, had affected many regions of the country.  A wave of HIV infection among Bangkok’s heroin injectors, caused by the sharing of blood-contaminated syringes, first occurred in 1988.⁵⁸  By October of that year, an estimated 40 percent of Bangkok’s injecting heroin users were HIV-positive, with as many as 5 percent becoming infected with HIV per month. 

In stark contrast to other groups at risk of HIV, such as sex workers and military recruits, HIV prevalence among Thailand’s injection drug users never dropped.⁵⁹  By June 2002, HIV prevalence among injection drug users at Thailand’s addiction clinics stood at approximately 40 percent, the same high figure as in 1988.⁶⁰  This figure may be as high as 60 percent in some regions, according to sentinel surveillance conducted in thirty-nine sites in 2000.⁶¹  The share of new HIV infections occupied by drug users has increased every year since 1990 and is projected to reach 30 percent by 2005, higher than any other group.⁶²

HIV infection among drug users also spreads to other persons, particularly drug users’ sex partners and children.⁶³  In Thailand, approximately 3 percent of the estimated 29,000 new HIV infections in 2000 (about 870 cases) occurred among women with needle-sharing partners.⁶⁴  The Thai Working Group on HIV/AIDS Projection estimated in 2001 that with a significant investment in programs that reduced needle-sharing among injection drug users, the number of new HIV infections in Thailand could drop from 29,000 in 2000 to 11,800 in 2006.  Without such an investment, the number of new infections in 2006 would be 17,000.⁶⁵

Ironically, Thailand is widely regarded as a “best practice” model in the reduction of sexually transmitted HIV through the promotion of condoms and safer sex.  An explosive epidemic of HIV/AIDS first appeared among sex workers in northern Thailand in 1989.  The first epidemic of its kind in Asia, it was unprecedented in its speed and, at its peak, affected up to 44 percent of sex workers in the northern Thai city of Chiang Mai.⁶⁶  By 1991, an estimated 15 percent of women in the sex industry in Thailand were HIV-positive.⁶⁷  During the temporary administration of Prime Minister Anand Panyarachun in 1992, the Thai government launched an aggressive “100 percent condom” campaign that aimed to combat HIV by promoting safer sex and condom use in brothels throughout the country.  Rates of HIV infection among sex workers dropped significantly by 1994 and continued to drop thereafter.⁶⁸  While up to one million Thais had already been infected, it appeared as though the country had been spared a destabilizing AIDS epidemic.

The philosophy behind Thailand’s condom promotion efforts was essentially one of “harm reduction.”  Harm reduction involves the acknowledgment of potentially harmful behavior, be it prostitution or drug use, and the attempt to reduce that harm in a pragmatic and respectful manner.  Encouraging sex workers and drug users to use condoms and sterile syringes, rather than insisting on immediate abstinence from sex and drugs, is the epitome of harm reduction.  Dr. Chris Beyrer, a leading expert on HIV/AIDS in Thailand, describes the philosophy underlying the 100 percent condoms campaign as follows:

Promoting condoms was not an attempt to restrict the sexual freedom of Thai men.  The army had tried this approach—punishing men for getting STDs, declaring brothel-going to be in contravention of the army code—and it was a complete failure: HIV rates were unchanged.  Condom promotion in commercial venues required the tacit acceptance on the part of the government, and the people, that while prostitution was illegal, it was widely available.  This was one of the most practical aspects of the campaign: by avoiding a moralistic and legalistic attack, it allowed ordinary people to continue their sexual activities, should they choose to do so, but with greater safety and with the government providing the condoms.⁶⁹

By analogy, the distribution of sterile syringes and related information to drug users is an effective and pragmatic method of HIV prevention.  Syringe exchange programs, whereby drug users obtain sterile syringes in exchange for used ones, have been shown repeatedly and in numerous countries to reduce infectious disease risk among injection drug users without increasing rates of drug use or drug-related crime.⁷⁰  Methadone, an orally administered prescription drug that manages opiate craving, also reduces disease risk by eliminating opiate users’ reliance on syringes and increasing their retention in drug treatment.⁷¹  These strategies may be contrasted with abstinence and prohibition, which take a “zero-tolerance” approach to drug use and attempt to eliminate its harms by eliminating the behavior itself, often ineffectively.

Despite the proven benefits of harm reduction programs for injection drug users, the Thai government has long refused to invest in these services.  The only needle exchange program ever to exist in Thailand, a small pilot project funded in Chiang Rai funded by the Australian government, was canceled when its funding expired.  In Thai prisons, where drug-related offenders accounted for 53 percent of those incarcerated nationwide as of 1999, severely limited access to sterile syringes can lead to widespread reuse and sharing of syringes among inmates.⁷²  Methadone is available through a national program, but treatment typically lasts twenty-one or forty-two days, after which patients are “tapered” off the drug even if they still crave opiates.⁷³  A 1991 pilot methadone program in Bangkok showed that patients who remained on methadone (a therapy known as “methadone maintenance”) were much less likely to return to heroin use.  However, it was not until 2000 that the Ministry of Public Health changed its policy to allow for ongoing methadone maintenance, and even then for a maximum of two years.⁷⁴  In February 2004, the United Nations Office on Drugs and Crime (UNODC) estimated that barely 1 percent of injection drug users in Thailand were receiving harm reduction services.⁷⁵

In 2003, a newly formed coalition of current and former drug users known as the Thai Drug Users Network (TDN) applied to the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria for a grant to fund HIV prevention services to the country’s drug users.  Global Fund grants are typically awarded directly to governments through a representative body known as a “country coordinating mechanism” (CCM).  However, in view of the Thai government’s lack of commitment to harm reduction, TDN argued that the money ought to bypass the CCM and go directly to a nongovernmental organization.  In October 2003, the Global Fund granted U.S.$911,542 to TDN for peer-based HIV prevention, care and support program for injection drug users—the first grant of its kind to a nongovernmental organization.⁷⁶

The lack of investment by the Thai government in harm reduction for drug users is especially troubling given the failures of drug treatment in Thailand.  In 2004, the Office of the Narcotics Control Board (ONCB) and the Bangkok Metropolitan Authority (BMA) estimated that fewer than 2,000 of the estimated 5,000 injection drug users in the Bangkok area were receiving in-patient treatment.⁷⁷  Drug treatment in Thailand is provided through a variety of public and private treatment centers, many of them hospital-based; as of 2001, there were an estimated 640 registered treatment centers in the country with 1,670 beds.⁷⁸  Many drug users in Thailand enter treatment through the criminal justice system, which typically refers low-level offenders to a “compulsory treatment center” pursuant to the 2003 Narcotic Addict Rehabilitation Act.  The law provides for a six-month rehabilitation period renewable for up to three years, after which authorities consider whether to institute criminal proceedings.

Coerced drug treatment and rehabilitation

Throughout the war on drugs, the Thai government took a number of coercive steps to enroll people in drug treatment programs in an apparent effort to reduce demand for illicit drugs.  These “demand reduction” strategies were doomed to fail, not least because they were conducted in a climate of extreme fear created by reports of blacklisting and extrajudicial executions.  According to experts, scores of Thais—some drug users, some not—reported for drug treatment during the war on drugs simply because they perceived it was the only way to avoid arrest or possible murder.  Others stayed away from treatment for fear of being identified as a drug user and subsequently targeted for arrest or worse.  A survey of 3,066 people who attended state-run rehabilitation centers from March 24 to April 4, 2003 (the period corresponding with the height of the war on drugs), found that 6 percent had never used any illicit drug before, and 50 percent had quit using before the war on drugs began.⁷⁹

Dr. Apinun Aramrattana, director of Thailand’s Northern Substance Abuse Center and co-author of the above survey, told Human Rights Watch that the Thai government had aimed to enroll 300,000 methamphetamine users in treatment during the drug war, based on a 2000 estimate of 300,000 methamphetamine users needing treatment in the country.  The government ordered regional health authorities to enroll a certain number of methamphetamine users in treatment, totaling 300,000.  Treatment centers used a dial-up internet connection to submit each patient’s name to a central server, which then cross-checked the names against a population database.  “Everything was done in such a rush,” Aramrattana said.  “There was no time to test the system, no time to train the people involved.  Eventually people just entered any name the system would accept.”⁸⁰ 

Aramrattana expressed concern that the “chaotic management” of treatment enrollment during the drug war could have lasting effects on the reliability of treatment data in the country.  “When they [health authorities] need to report statistics to the government under threat of penalty, can you believe any number they give?  We are already seeing that they report any number to the government under pressure, and the government announces this as an official figure.”

Interviews with drug users suggested that many people did not enter (or remain in) treatment voluntarily, but rather that police essentially required it.  “If they [the police] see me, I present a card as proof that I’m in treatment at a medical center,” said Chuai N., thirty-six, who had been injecting heroin for over ten years.  “If you have an ID showing you attend treatment, you are considered a ‘patient,’ so they don’t arrest you.”⁸¹  The few times he had been arrested, Chuai N. said, he was charged with possession of narcotics after the police planted drugs in his pocket.

Drug users who chose not to seek treatment during the war on drugs also said they were acting out of fear.  “It’s something to do with the individual’s perspective,” said Odd Thanunchai, twenty-six, a peer educator and recovering heroin user in Chiang Mai.  “If you go to treatment or boot camp, you are documented.  You can’t guarantee what’s going to happen to you afterwards, so you would rather not come forward.”⁸²  According to one statistic, the number of heroin users attending the Northern Drug Dependency Treatment Center (NDDTC) dropped from fifty to eighty users per month before the war on drugs to less than ten users per month after.⁸³

With respect to the quality of treatment provided during the war on drugs, addiction specialists observed that the government seemed more determined to fill treatment quotas than to address drug addiction in any meaningful way.  The typical course of treatment consisted of a series of disciplinary drills in a military-style “boot camp,” after which drug users were declared “drug-free.”  The boot camps did not screen attendees properly, nor did they provide follow-up to prevent relapse.  “Maybe they [the authorities] don’t want to bother with follow-up because they would see that people have relapsed,” said Dr. Jaroon Jittiwutikarn, an addiction specialist and former director of the NDDTC.  “They would rather declare victory based on the number of admissions to boot camp.”  Aramrattana added that the boot camps risked giving users a false sense of recovery from their addiction.  “The idea was that if drug users registered for treatment during the period [of the war on drugs], they would gain more acceptance from the community for being drug-free,” he said.  “People think they no longer need treatment after that, because the incentive from their family, parents and teachers is gone.”

The quality of methadone treatment provided to heroin users was also questioned by some.  While Thai law allows for long-term methadone “maintenance” therapy, which has a high success rate in eliminating heroin cravings, most clinics offer only twenty-one days of methadone detoxification before “tapering” patients off the drug.  Experts, including the World Health Organization, agree that this is not sufficient to eliminate opiate cravings.⁸⁴  Karn S., twenty-five, described how her heroin cravings returned as soon as the twenty-one days expired.

They gradually reduce the dose over twenty-one days and on our last day there’s hardly any left.  When I get to that point, I begin to crave, and I need to find heroin as a substitute.  I need to find it right away, because they make me wait seven days before I can be admitted to another twenty-one-day program.  This is going on even now.  The last time I used heroin was about two or three months ago.  I didn’t get my methadone in time, so I needed to find heroin.  I get it from dealers in the province, or sometimes in Klong Toey.⁸⁵

Muay C., twenty-six, said that she had been through three forty-two-day methadone programs before the war on drugs started in February 2003.  “I heard about the drug war on cable TV,” she said.  “I was afraid a little of being arrested, afraid of not being able to find heroin.  A lot of people I know were arrested.”⁸⁶  She said at first she began asking a friend to purchase heroin for her, but eventually she tried quitting again.  “I did the detox program at the psychiatric hospital near the airport two or three months ago,” she said.  “It’s very painful, and I don’t sleep well at all.”   At the time Human Rights Watch met her, Muay C. was still using heroin periodically and was becoming addicted to sleeping pills.

Some drug users also complained of arbitrary restrictions imposed by methadone providers.  Methadone is typically administered in a daily dose taken orally in liquid form.  Some methadone providers, including in Chiang Mai, permit drug users to take home a supply of methadone to avoid the inconvenience of having to attend the clinic every single day.  Most methadone patients interviewed by Human Rights Watch, however, said that their clinic refused to allow them to bring home a supply of methadone, not for clinical reasons, but for fear that they would sell the methadone on the street to earn a profit.  This arbitrary (and highly onerous) requirement did not apply to other prescription drugs with a potential street value, such as sleeping pills or painkillers.  Noi N., thirty-seven, described his daily methadone routine as follows:

I go to [the methadone clinic] every day.  I take a bus—it can take up to two hours if the traffic is bad.  The methadone is only effective for two days.  [If they give us some to take home,] they are afraid we will sell it to somebody else.  I really want to take more home, but they won’t let me.  They’re afraid I’ll sell it.  The only place you can get methadone is in a medical center.  My girlfriend works in a factory and I also sell clothes, so I don’t have to work all day.  I haven’t missed a day yet.  If I miss the morning, I go in the afternoon.  No one is allowed to take methadone home.⁸⁷

Some drug users said that if they missed a single day of methadone treatment, they turned to heroin to satisfy their cravings.  “Last month, there was a holiday and the center was only open for half a day, so I didn’t make it in time,” said Reib S., twenty-seven, who began injecting when he was twenty and is HIV-positive.  “I needed to find some drugs, so I bought B300 [U.S.$7] worth of heroin.”⁸⁸  Reib S. said that on one such occasion, the police arrested him and he spent a month in jail without any access to methadone therapy.

Once, about two or three years ago, the police caught me.  I got picked up on my way back from buying heroin, so I had the drugs on me.  I spent a month in jail.  It was hard.  There were too many people in there.  There was no methadone, no heroin.  I had to tough it out.  I was in a lot of pain.  I couldn’t sleep, I just craved for it.  After I was released, I went back to using for about two months before getting onto methadone again.

The Thai government’s systematic use of fear to force people into treatment, combined with the inadequate course of treatment offered and the lack of follow-up, showed little to no appreciation for the chronic and relapsing nature of drug addiction.  “I’ve tried treatment thirty or forty times,” said Tum N., twenty-four, who began injecting heroin at seventeen.  “They give me methadone and reduce the dose until there’s none at the end.  After you finish, you just go home.  By the time the dose gets really low, I go back to heroin.”⁸⁹  Ngu L., twenty-three, said that he first tried drug treatment in a monastery when he was fifteen, the year he began injecting heroin.  When he entered a methadone program in April 2003, three months into the drug war, it was his seventh attempt.

Driving drug users “underground”

Long experience, including with Thailand’s sex industry, shows that fear of arrest and police abuse can drive people at high risk of HIV infection “underground” and away from potentially life-saving HIV prevention and other health services.  The available evidence suggests that this is precisely what occurred during Thailand’s war on drugs, during which fear of arrest was magnified by reports of rampant police killing of drug suspects.⁹⁰  Odd Thanunchai, twenty-six, a peer educator for the nongovernmental organization Population Services International (PSI) in Chiang Mai, described the fear that gripped Thai drug users during the war on drugs.

They felt their life was threatened, that they might be killed or arrested.  So they went where they felt safe, where they couldn’t be identified with other drug users.  Some even escaped and went to live in the mountains, or moved into a friend’s house.  Some just lived by themselves in hiding.  There’s one person I went to see at his house.  I know he’s there, but his family told me he wasn’t even there.⁹¹

As a peer educator for “O-Zone,” a drop-in center for drug users run by PSI, Thanunchai said that the war on drugs made it more difficult for him to reach drug users with HIV prevention and other health information.  “All my peers disappeared from the scene and hid themselves,” he said.  “It’s not like before when you could go outside and you knew who the drug users were . . . . Before, it was easy to find a group and know where the gathering place was.  After the war on drugs, people disappeared because they didn’t feel safe.”

The precise impact of the war on drugs on drug users’ health is difficult to research, not least because of the climate of fear surrounding drug use itself.  A researcher with a randomized study of HIV prevention among drug users conducted by Johns Hopkins University, Chiang Mai University’s Research Institute for Health Science, and the Northern Thai Drug Treatment Center, said that most of the 340 people recruited for the study simply disappeared when the crackdown began.  “We lost sight of about 270 to 280 people within two or three weeks,” the researcher told Human Rights Watch.  “Some were definitely killed, some went underground . . . . The fear was insane.  The ones we were in contact with reported going underground and reported sharing syringes.”⁹²

The coordinator of O-Zone, Anurak Boontapruk, told Human Rights Watch that “it’s hard [during the war on drugs], because they [the drug users] are hiding from us.  They are more spread out.  Either they move or they get arrested.”⁹³  Boontapruk added that he felt drug users’ risk of becoming infected with HIV increased, because drug users continued to find ways to inject drugs but without access to information on HIV prevention.  “Some drug users have told us that when they are in hiding, many risky behaviors happen,” he said.  “I think they’re at greater risk of HIV, because it’s hard for individuals or organizations to work with this group now, including for research, education, or access to health services.”

Fear of arrest may have been particularly pronounced for drug users in northern Thailand who were also migrant workers from neighboring Burma, according to Jackie Pollock of the Chiang Mai-based Migrant Assistance Program (MAP).  Pollock said that outreach workers attempted to educate migrant workers about health issues, including drug use, but it was difficult to talk openly about drugs during the crackdown.

During the war on drugs, I think levels of fear tripled . . . . Rumors went around for a year.  Friends of migrant workers were saying their friends had come from Burma and the police stopped them, and they ran and got shot.  We assumed it was drug-related, because normally migrants running away from an illegal raid wouldn’t get shot.⁹⁴

Pollock added that heightened levels of fear made it difficult to conduct effective outreach work with drug users, especially in previously underserved areas.  “When people’s level of fear of arrest increase, that makes it difficult to reach them,” she said.  “Everyone was afraid we might be an informer.  It takes a long time to establish their trust.”  Although the government had made some efforts to encourage drug users to seek treatment, including by posting signs in public places throughout Chiang Mai, Pollock said that migrant workers may not have grasped the subtlety of that message. “Migrants don’t even read Thai,” she said.  “They don’t pick up on the subtleties of ‘drug trafficker’ versus ‘drug user.’  And of course, all the people who were getting caught were the middle people”—meaning, in her view, low-level drug traffickers who may have been selling to support their families or to finance a drug habit.

In a suburb of Bangkok, Human Rights Watch interviewed a peer educator who had established an underground syringe exchange program as part of a hospital-based drop-in center for injection drug users.  He and his colleagues provided sterile syringes, condoms, and counseling on the safer use of heroin and amphetamines to approximately thirty clients per week.  “If the police knew about it [the syringe exchange], they would probably arrest us,” said the peer educator.  “So it’s a risk.  Every day I carry the syringes in my bag.  It’s a bit underground.  Luckily I’m not from around here, so the police don’t have a record on me.”⁹⁵  The educator added that the war on drugs made reaching drug users even harder than usual.  “Obviously the war on drugs has had some effects on our work.  It’s much harder to get people involved in the drop-in center, because it’s located in a public establishment and they feel if they come here they will be arrested.  The clients are also afraid they will be recognized as drug users and targeted for arrest in the future.”  The risk of arrest also made it impossible to collect used syringes for safe disposal, he said.  “It’s rather dangerous to carry a syringe around with you in case the police find it, so you need to find a way of giving them out without getting them back.” 

Epidemiological surveys of drug users’ behavior during the war on drugs corroborate some of the testimony gathered by Human Rights Watch.  The Johns Hopkins/Chiang Mai University study noted above showed that 37 percent of drug users who had formerly attended drug treatment centers in Chiang Mai went into hiding during the war on drugs, in some cases sharing syringes because sterile syringes became more difficult to obtain.⁹⁶  The same study suggested that many drug users had stopped injecting heroin during the drug war, but that a large number of those had switched to other forms of illicit drugs, alcohol consumption or sleeping pills.  Boontapruk from PSI observed several increased risk behaviors during the war on drugs, including switching to other drugs or alcohol and risking fatal overdose by injecting too quickly.

Some heroin users switched drugs but continued to inject.  Some started using ya baa or other pills.  Some just turned to using strong alcohol like whiskey, which can cause accidents.  When you’re hiding from the police, it’s very difficult to have drugs on you, so you need to use them in a hurry.  This can cause overdose.⁹⁷

According to the Johns Hopkins/Chiang Mai University study, a significant percentage of drug users who stopped injecting heroin during the war on drugs either sought drug treatment (38.3 percent) or quit “cold turkey” (39.0 percent).⁹⁸  Most heroin users said they had stopped injecting because of the reduced availability of heroin.  As of this writing, no follow-up data is available on whether these users subsequently relapsed.

In July 2003, hours after researchers presented some of the above findings at the Ninth National Conference on AIDS in Bangkok, Thai police raided the researchers’ offices in Chiang Mai and demanded to know the location of the study participants.  “They wanted to know where the drug users were,” a researcher who was present at the raid told Human Rights Watch.  “It was five or six police officers.  They pretty much wanted to know why we were in touch with drug users and where they were . . . . They were Chiang Mai local police, who had obviously been contacted from Bangkok and sent in . . . . It was the most efficient policing I’d ever seen.”⁹⁹  The researcher said that the office had enjoyed good relations with narcotics officers before it was raided, and that researchers explained to them that it would be unethical to reveal the identities of research subjects.

It is important to note that even before the war on drugs, Thai drug users had severely limited access to HIV prevention services such as syringe exchange and methadone maintenance therapy.  Community-based peer interventions such as those described above attempted to fill this gap by at least providing drug users with basic information about safer sex, use of sterile syringes, prevention of fatal overdose, and methadone.¹⁰⁰  During the war on drugs, however, the Thai government has made no attempt to mitigate or even evaluate the impact of its anti-drug policies on these limited interventions.

Penalties for syringe possession

Public health authorities consistently recommend that for people who cannot or will not stop injecting drugs, using a sterile syringe for every injection is the most effective way to prevent HIV and other blood-borne viruses.¹⁰¹  In Thailand, it is common for injection drug users to purchase new syringes in pharmacies without needing a prescription to do so.  Human Rights Watch found, however, that Thai police frequently used possession of sterile syringes as sufficient evidence with which to make an arrest, whether for possession of drug paraphernalia or narcotics.  Some drug users said they feared purchasing syringes in pharmacies because these arrests would sometimes occur in the vicinity of the pharmacy itself.

Kor D., twenty-six, told Human Rights Watch he began injecting heroin when he was about eighteen.  He knew that sharing syringes posed a risk of HIV transmission, he said, but it was difficult to carry sterile syringes without being identified by the police as a drug user.

I live in a slum that’s well known to have drug users.  You have cops walking around.  If they pick you up and see needle markings on your arm, they just arrest you.  It gets even worse if you have a syringe with you, unless of course you have a certificate saying you have a disease that requires injection, like diabetes.  The way I look, with all my tattoos, the cop doesn’t have a second thought about picking me up.  The cops arrest you for drug possession, even if you don’t have any drugs with you.¹⁰²

In 2002, Kor D. tested positive for HIV.  “I suspect it was probably from sharing syringes,” he said, adding that he knew the risk he was taking.  “I had no other choice, because I craved for it and had only one syringe.  I had to use it.  This situation happened many times.  The place where I buy syringes is far from my home.  There’s also a risk of getting arrested by police, and I don’t have much money.”

Karn S., twenty-five, said that buying syringes felt illegal, not unlike buying heroin.

I buy my syringes from a drug store.  It’s quite easy, but you need to watch out for the cops.  If the cops see it, they’ll arrest you right away, inside the store.  If the cop knows that a storeowner is selling syringes to a drug user, the owner will get arrested, too.  I need to look around for the police going in and buying a syringe.  Once it’s safe, I just go in and buy it.  It’s just like buying drugs—you need to be careful.¹⁰³

Muay C., twenty-five, described a similar risk in Chiang Mai.  “You have to be careful going to the drug store to buy syringes,” she said, adding:

You have to hide them [syringes] in your underwear.  The last time I tried was the beginning of this month.  I went into the drug store, quickly gave them the money and put the syringe straight into my underwear.  I used that syringe a few times.  [Whether I reuse syringes] depends on how much heroin I have.  If I have a lot, I reuse more often.  One time I was really craving and I shared.¹⁰⁴

Drug users recounted arrests not only outside pharmacies, but also outside methadone clinics.  Peer educator Odd Thanunchai said that he had been using methadone irregularly for approximately three years when, in 2002, police in Chiang Mai stopped him and arrested him on his way to the clinic.

I came to the clinic in the morning to pay for my methadone, and then I drove my motorbike to an area behind the teacher’s college.  I had no drugs on me when I left the clinic.  I was thinking about parking my bike, but then a police officer walked out from a small lane—it’s a very small street, and someone standing there can grab you very quickly.  The area is known as a drug-dealing area.  The police asked me, “Why are you here today?,” and I tried to give a reason.  Because they knew me as a drug user, they didn’t believe anything I said.  They assumed I was coming for drugs.  When you come across them, there’s no way to get away.  They sent me back here [to the methadone clinic] to get my change, and then they took me to the police station for two days and one night.¹⁰⁵

Following his arrest, Thanunchai said he was sentenced to six months in prison for using drugs.  “They [the police] didn’t do much to prove I was a drug user,” he said.  “They just said, ‘This is the same old face.’”  Thanunchai said it was “not worth having a lawyer” to fight the charge, because that would only lengthen the time he spent in pre-trial detention awaiting a trial.  “It consumes a lot of time and money just for a shorter sentence,” he said.  “If you have a lawyer, it might actually lengthen your time in jail because the process takes longer, so you spend more time in detention.”

Dangerous practices fostered in detention facilities

A predictable outcome of Thailand’s drug policies, which emphasize criminalization over humane treatment and harm reduction, is that many active drug users spend time in prison or pre-trial detention.  A 2002 study of 1,865 injection and non-injection drug users in Chiang Mai found that 27 percent had been jailed in their lifetime, and that 55.2 percent of those who had ever injected had been jailed.¹⁰⁶  The incarceration of active drug injectors presents an enormous public health challenge, as evidence shows that drug users often continue to inject in jail and prison (and following their release), often sharing syringes with their fellow inmates.  Incarceration is strongly associated with HIV infection in Thailand, particularly for men.  In the above survey, of 104 male injection drug users who had been jailed, 38.2 percent were HIV-infected, compared to 20.2 percent of those who had not been jailed.  Among male injectors who admitted to having used drugs in prison (15.8 percent of those who had been jailed), 48.8 percent had HIV.

Interviews with ex-inmates showed that prison authorities in Thailand were taking few if any steps to address—or even evaluate—the enormous risk of HIV infection among incarcerated drug users.  Ngu T., twenty-three, said he was sent to prison for two years in 2002 after a police officer found syringe markings on his arm.  “The police stopped me and looked at my arm and said, ‘You’re a drug user,’ and picked me up,” he said.  “I was in prison for two years.”  He described his drug use in prison as follows:

It’s easier to get heroin in prison than outside.  They have dealers inside prison.  It’s not that expensive, about B400-500 [U.S.$10-$12] per pack.  It’s a bit more expensive outside.  We get syringes from some medical station inside the prison.  I took them myself, they were proper syringes.  You need to share needles, there’s never enough.  I’d share with over fifty people.  I didn’t have a choice.  When there’s only one, you have to use it.  It’s not very sharp, but you have to use it.¹⁰⁷

Following his release from prison in 2003, Ngu T. tested positive for HIV.  “I probably got infected in prison, because I was sharing needles,” he said.  “I shared before prison as well, but I still believe I got AIDS when I was in jail, because the sharing is more widespread.  I realized the risk, but I craved it, and nothing would stop me.”

Some drug users told Human Rights Watch that before they were arrested and sent to prison on drug charges, they had been making progress in addiction treatment.  Peer educator Odd Thanunchai said he spent between two and three months in jail after police stopped him on his way to a methadone clinic.  “There were drugs in prison—all kinds,” he said.  “The situation in prison and here outside is just the same.”¹⁰⁸  He added that prison inmates fashioned homemade syringes out of needles and intravenous tubing, which they shared. 

We put the [drug] solution in an IV tube, and we blow on the tube to put pressure on the solution to get it into a vein.  It really takes a lot of effort, making sure you blow with the right pressure.  We mostly share the same equipment.  It’s expensive, so we buy one injection of heroin, prepare it in a bottle cap, and there’s one person, the injector, who makes sure everyone gets the same portion.  Between each person, the injector takes water in his mouth and blows it through the tube to clean the equipment.

Asked how many people shared the injection equipment, Thanunchai said, “About three or four . . . . The way we do it is, four people will put their money together and buy an injection [of heroin] and then go to someone to rent the equipment.  His fee would be a portion of the injection, so it becomes five instead of four.”

Although many drug users in Thailand avoid prison time for low-level offenses, most still spend time in pre-trial detention following their arrest.  Yai T., twenty-eight, described sharing syringes in a Bangkok-area jail in 2002.

I was in jail in 2002 for two months before I went to court and was released.  When I was in jail with the other drug users, everyone craved heroin and you couldn’t find a syringe.  So you took a straw from an orange juice packet and used it to inject.  There were needles in the jail that had been left behind by someone else, or we would ask somebody else to smuggle them in.  We’d connect the needle to the straw and blow in.  Seven or eight people would share the equipment.  Before us, I wouldn’t know how many, maybe hundreds.  When you crave heroin, you don’t give a damn about whether you get infected with HIV.¹⁰⁹

Yai T. added that “there is no HIV testing in jail, no information about AIDS.  You just get a normal health check [in the medical clinic], or treatment for a cold or stomachache.”

Kor D., twenty-six, who is HIV-positive, said that when he was in jail in the 1990s, people would smuggle in syringes or else make their own syringes out of sharpened ballpoint pens.

People would hide syringes in their anus and then take them out once they got into jail.  The search is not as detailed in jail as it is in prison.  There’s never enough, so they share needles in jail as well.  You only need a needle and an IV tube, or even a pen.  You sharpen it up, take out the ink, stick it in you and blow.  The people who supervise the jail know this is going on.  It depends how much you bribe them.¹¹⁰

Other interviews suggested that instead of taking steps to reduce HIV risk among inmates who injected drugs—for example, by providing information on HIV/AIDS or substitution therapy—guards simply punished inmates who used drugs.  Noi N., thirty-seven, told Human Rights Watch that she was too scared to use drugs in prison because “if you get caught using drugs in jail, you can get killed or beaten up so badly you almost die.  Or you get beaten repeatedly until your health deteriorates.”  But there was no adequate program to deal with her addiction.

I needed just to bear with it, to tell myself I couldn’t use or else I’d get caught.  Some people can’t stand it and just use, and they get caught and beaten.  I craved it a lot and got tired and fatigued.  The only thing they gave me was a painkiller, like paracetamol.¹¹¹  There is no methadone in prison.  I never asked for it—just for asking, I might get myself beaten up.  If I asked, the guard would take it to mean that I hadn’t repented for my crime, that I’m still thinking about drugs and need to be punished.¹¹²

Rather than recognizing the extent of injection drug use in prison and taking steps to mitigate HIV risk, Thai authorities appear to be turning a blind eye to the problem.  A policy analyst with the Office of the Narcotics Control Board (ONCB), who does not represent the correctional system but who spoke knowledgeably about HIV prevention policy among Thailand’s drug users, stated that basic HIV prevention services, including methadone maintenance, would not be made available in Thai prisons.  “Not in that place [prison],” she said, “because that place is supposed to be drug-free, and if they go through withdrawal, they have a doctor to provide them with other treatment.”¹¹³  The analyst also questioned the extent of heroin use in prisons, saying, “sometimes we have relatives trying to send drugs to offenders in jail, but we try very hard to stop this.”  A 2004 Harm Reduction Action Plan prepared by Thailand’s Ministry of Public Health calls for an evaluation of the situation of drug use and HIV/AIDS in prisons, but as of January 2004 the participation of the Department of Corrections had not been finalized.

State and international response to health impact of the war on drugs

Human Rights Watch met with officials at the ONCB and the Thai Ministry of Public Health about the adequacy of addiction treatment and HIV prevention services for drug users in the country.  Supodjanee Chutidamrong, a policy analyst with the ONCB, stated that all drug treatment was voluntary in Thailand unless a drug user was arrested, in which case low-level offenders were sent to compulsory treatment and high-level or multiple offenders received treatment in prison.  All low-level offenders underwent an evaluation for fifteen to forty-five days evaluation by a Rehabilitation Subcommittee prior to being placed in either outpatient treatment or a compulsory treatment center.  From the implementation of this policy in March 2003 to January 2004, 12,263 drug users had entered compulsory treatment, she said.

Compulsory treatment centers, like prisons, provided rehabilitation through the Therapeutic Community (TC) model,¹¹⁴ even for heroin users who might have required substitution treatment.  Asked why methadone was not available outside voluntary treatment programs, Chutidamrong said that by the time most drug users completed their evaluation and entered treatment, they had gone through withdrawal and no longer needed opiate substitutes.  She also noted that most drug offenders did not use opiates but methamphetamines, which did not respond to substitution therapy.

The distribution of sterile syringes to drug users does not figure into Thai AIDS policy, and is opposed by senior members of the drug control establishment.  In 2001, the deputy secretary general of the ONCB, Rasamee Vistaveth, assumed the chair of an interagency task force on harm reduction established at the recommendation of the World Bank.  According to Sompong Chareonsuk, a country program adviser (field officer) for UNAIDS who coordinates the task force, Vistaveth soon stepped down “because the ONCB had no harm reduction mandate.”¹¹⁵  In 2002, the Thai government reconstituted the task force as the National Working Group on Harm Reduction, apparently in anticipation of its hosting the Fifteenth International AIDS Conference in 2004.  The working group developed a seven-point plan of action with a budget of approximately U.S.$150,000, all of it donated by either UNAIDS or the United Nations Office on Drugs and Crime (UNODC).¹¹⁶  As of mid-2004, none of the grants awarded directly to the Thai government by the Global Fund to Fight AIDS, Tuberculosis and Malaria contained targets for increasing harm reduction services for injection drug users.

Chutidamrong of ONCB said that the Ministry of Public Health “has concluded that needle or syringe exchange is disadvantageous.”  She added, “We have a very strong drug prevention policy.  The government is supposed to say to people, ‘We have a drug-free society.’  But maybe if you give syringes to drug users, young children will think, ‘What does that mean?’”  Asked about the success of a pilot syringe exchange program funded by the Australian government in Mae Chan, Chiang Rai in the 1990s, she said, “They said it was successful, but the Mae Chan project may not be applicable in the lowlands.  They did it with hill tribes, but if they did it with lowland people, I’m not sure it would be effective or wouldn’t have harmful effects.”  Chutidamrong’s statements do not necessarily reflect the views of health officials in the Thai government.  However, in practice, no syringe exchange program exists in Thailand with government support, despite significant government expenditure on other aspects of HIV prevention.

Despite the enormous impact of Thailand’s war on drugs on the human right of drug users to obtain the highest attainable standard of health, there was an almost complete lack of condemnation of the drug war by international organizations charged with protecting public health or monitoring human rights.  Agencies such as UNAIDS, WHO, and the Global AIDS Fund remained largely silent on Thailand’s drug war even as they committed substantial resources and technical assistance to the country’s HIV prevention programs.  In September 2003, during the second phase of the narcotics crackdown, the United Nations Children’s Fund (UNICEF) celebrated Thailand’s “100 percent condom” campaign without making any mention of the country’s ongoing repression of drug users.¹¹⁷  The Global AIDS Fund had as of mid-2003 awarded three grants totaling U.S.$51,006,387 to the Thai government without including any human rights requirements in its grant agreements, despite having been urged to include such requirements.¹¹⁸

Injection drug use and the human right to health

Thailand is a state party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), article 12 of which guarantees all individuals the right to the “highest attainable standard of health.”¹¹⁹  Article 12(c) specifically obliges states to take all steps “necessary for . . . [t]he prevention, treatment and control of epidemic . . . diseases” such as HIV/AIDS.  This clause has been interpreted by the Committee on Economic, Social and Cultural Rights, the U.N. agency responsible for monitoring implementation of the ICESCR, as requiring “the establishment of prevention and education programmes for behavior-related health concerns such as sexually transmitted diseases, in particular HIV/AIDS.”¹²⁰  Even more immediate is the requirement that states not interfere with existing health services.  According to the Committee, “[t]he obligation to respect [the right to health] requires States to refrain from interfering directly or indirectly with the enjoyment of the right to health.”¹²¹

Programs such as syringe exchange and methadone maintenance are among the most well researched HIV prevention strategies in the world.  Studies consistently show that access to sterile syringes dramatically reduces HIV transmission without increasing rates of drug use or drug-related crime.¹²²  The World Health Organization states that “[needle exchange programs’] ability to break the chain of transmission of HIV is well established.”¹²³  Syringe exchange programs provide a bridge to drug treatment programs by providing clients with information, counseling and referrals.  The concern that syringe exchange “sends the wrong message” about drug use, expressed by many policy makers, both lacks an evidentiary basis and amounts to an effective death sentence for people who cannot or will not stop using drugs.

Research supporting the establishment of methadone maintenance programs, including research conducted in Thailand, is equally compelling.  A pilot methadone maintenance project conducted by the Bangkok Metropolitan Authority in 1991 showed that drug users who remained on methadone were more likely to stay in treatment and less likely to return to heroin use.¹²⁴  Longer retention in treatment is in turn correlated with a reduction in HIV risk behaviors, according to evidence cited in a 2004 position paper by the World Health Organization, the United Nations Office on Drugs and Crime, and the Joint United Nations Programme on HIV/AIDS.¹²⁵  The same position paper found a correlation between substitution maintenance and reduced death rates for people with opioid dependence; fewer complications for pregnant women and their children; higher annual earnings and employment levels; and reduced levels of criminal activity.  The paper also noted that the risks associated with substitution maintenance, such as overdose and diversion of methadone into black markets, could be minimized by low doses at the beginning of treatment and effective oversight of methadone programs respectively.

In the face of this scientific consensus and in the absence of equally effective alternatives, state-imposed barriers to harm reduction programs for injection drug users constitute interference with the human right to health.  To the extent that drug users suffer from addiction-related disabilities, restricting these programs may also constitute a form of discrimination in access to health care.¹²⁶  The unique clinical challenges posed by drug addiction, including the high risk of HIV infection, oblige governments to tailor their health care services to drug users’ needs rather than restricting safe and effective programs in the name of drug prohibition.

The many civil and political rights violations associated with Thailand’s war on drugs—extrajudicial killings, blacklisting of drug suspects without due process, and arbitrary arrest and police abuse—also implicate the human right to health.  The fear of being mistreated or worse by police has driven drug users into hiding and away from potentially life-saving health services.  Though the full health impact of Thailand’s drug war has yet to be fully investigated, interviews conducted by Human Rights Watch as well as other evidence suggest that the campaign sharply increased drug users’ risk of HIV and other health complications.  The Thai government’s deliberate use of fear tactics to deter drug activity, combined with its failure to take any effective steps to mitigate the health impact of its war on drugs, must be viewed as a failure to protect drug users’ right to the highest attainable standard of health in violation of its obligations under the ICESCR.