Side event: Forced treatment, people who use drugs and the right to health: empirical evidence from Asia and Latin America

Organized by Equis Justicia Para Las Mujeres A.C., the International Drug Policy Consortium, and the Office of the High Commissioner for Human Rights

Leigh Toomey, Vice Chair, UN Working Group on Arbitrary Detention: (Intro)

Annette Verster, World Health Organization: Health and welfare of humankind are the fundamental underpinnings of the Conventions. This is very important also in recent documents that have come out from UNGASS, and also the UN Common Position on Drug pOlicy. When we talk about drug use, to put into perspective, we talk about different things; different substances, modalities of use, and I won’t repeat the numbers on the screen (ex. 271m used drugs in 2017, vs 1.1 billion for tobacco or 2.3 billion for alcohol). The burden of health related to drugs is inferior to controlled drugs because prevalence is much smaller. Why we focus usually on injection drug use? Because injecting drug use fuels epidemics of HIV and HepC. Much of our attention for HIV, but HepC numbers are dramatic. Only 8% of people living with hepatitis have been infected in relation to injected drug use. But new infections are increasing among people who inject drugs. WHO promotes the inclusion of a comprehensive package of interventions (adopted in 2009) in relation to harm reduction. But also seeks to address structural barriers to interventions that reduce further transmission of infectious diseases. Here, it is key to highlight the need to work towards the decriminalisation of possession for personal use. The comprehensive package is essential but we also need to consider other forms of interventions that are beneficial. The comprehensive package and harm reduction interventions are only partially implemented though. Most people don’t have access to these services. With regard to stimulant use, the package and the foucs of our work has been mostly opioids and injecting (for the reasons I explained earlier). But the situation of the response for stimulants is more lacking. We need effective, innovative and impactful prevention and treatment. A review of interventions showed that there aren’t evidence-based interventions that are psychosocial and pharmacological. One of the reasons for this dearth is that the problems that relate to stimulant use (barriers to services, stigma) result from government’s punitive responses. Involuntary treatment is a human right violation and not recommended by WHO. IN 2012, there was a joint UN position on compulsory rehabilitation. 12 agencies called on states to close these centres. While closure is pending, that they have access to essential services. Compulsory detention isn’t treatment. The human right to the highest attainable level of health means that healthcare is evidence based, voluntary and community based, available, accessible, affordable, based on informed consent, with health data treated with respect, with community involvement, and monitored and evaluated for success. There are opportunities, however, with regard to political agreements. WHO is working on UHC, for instance, which provides a framework for not leaving anyone behind and for people who use drugs this means equal access to quality, prevention, testing and treatment. Finally, I wanted to highlight the importance of the UN Commons position, the SDGs, the UNGASS Outcome Document.

Corina Giacomello, Equis Justice for Women – Mexico:  We conducted research in 5 centres. Women were mostly in compulsory treatment centres. I will focus on what they said about their lives, their involvement in drugs, and the conditions of imprisonment. Some generalisations to stay within the time allocated. Of all the women, and boys, they all experienced some level of violence during childhood. Most women revealed they had been sexually abused. Almost always men in their close circles. Rarely reported. Most of the times they were accused of lying or provoking them. Some would end up in violent relationships with older men. Other cases, they would live in the streets and co-opted by organised crime. When we refer to drug use, they talk about it as a means of resilience, to be accepted by relationships, to face trauma. Most of these women are victimised. And the response by the State is more violence in prisons or compulsory detention. The idea that drug use is moral failure reinforces the victim-blaming discourse. Society has failed these women. A file is opened for these women only when they’re in prison, not when they’re the target of violence. People in these spaces were signed in by families. Children can be there too. Some don’t use drugs. They can be kept in there for an indefinite amount of time. No support by the State. They’re stigmatised, and their human rights violated. Sometimes they have been kidnapped to intern them. 3 months usually, but sometimes more. After 15 years of doing fieldwork in prison, this was a shock…their living conditions are terrible. Not all treatment centres are like this but we’re focusing on the worst cases of violations. Waking up alive is a probability…not a certainty. EQUIS has been working in this field for 5 years; we want to make sure the voices of these women are heard. We’ll publish a policy brief very soon.

Alexander Söderholm, London School of Economics and Political Science: There is increasing evidence in terms of the lack of effectiveness of compulsory treatment. Colleagues organised a systematic review and showed it’s not useful or effective. If we look at compulsory drug detention centres, the literature is growing while limited showing they’re also ineffective and individuals are more likely to relapse (compared to OST). In Iran, these “camps”, as they’re called, do not address the social and economic vulnerabilities that need to be tackled. And there’s no follow up afterwards either. Iran is quite a unique case because of the scale of the problem. 20% heroin seizures, 91% of opium seizures. The government says that there’s 2.8 million “addicts”. Iran has been at the forefront of harm reduction in the region (NSP -trial- and OST services in prison). But since 2010, these centres have become part of the law and a decline in harm reduction orientated services. The law describes two types of “addicts”: voluntary joining a treatment programme (certificate supposedly exempting them from prosecution), and the ones that do not voluntarily stop using drugs (they can be mandated to enter “treatment” in these camps for 1-3 months). In 2013, 18 compulsory centres under Art. 16. 50,000 people in these centres. They’re supposedly accredited by WHO and Min Health, or ran by law enforcement. The focus is 12 steps, based on NN.AA. Seldom followed, usually nonevidence based approaches. IN terms of referrals: forced – arrest, doctor confirms drug use, judge reiterates, and then mandate to go into a camp), family referral (family, then police), and, in very rare cases, self-referral. In terms of guidelines, very little oversight. They’re de facto holding facilities for “deviants”. The police will mop up people living homeless, sex workers, people with mental health and effectively selling them to the camp. They’re supposed to be 12 step but what happens is that they’re thrown into cold water pools during winter, dire conditions. This research was based in my observations and discussions with people who use drugs. The reality is that police get money for bringing users into camps. The family might refer individuals and the wardens come pick them up themselves. Some quotes from open air markets: people enter with dependence to a substance, and they end up using more; sometimes they sell substances in the camps. They report beatings. In some cases, held for over a year. Medicines are often not allowed… Studies emerging in these settings: of 371 camps, high mortality rates (8x than voluntary centres)…and in voluntary centres they were already high. Key takeaways: high mortality rates, lack of systematic research, no evidence base, unclear guidelines, corruption, they don’t address the contextual factors.

Henrique Apolinario, Conectas:  It’s a bit depressing when I hear of all the harm reduction and other interventions around the world, during CND, and I think of the situation in my country, where this is unavailable. Brazil has a terrible history of internment. In 2001, reviewed after international outcry. The new federal administration has seen a new system of forced treatment created, decentralised, focused on people who smoke cocaine. 2019, new drug law created a system of forced treatment not dissimilar to the Iranian one. The government created a drug policy based on abstinence, passed by decree; drives resources and people away from harm reduction and into forced “treatment”. The law guarantees treatment should be voluntary but doesn’t ensure informed consent. In a context of austerity, people are channelled into these treatment centres. There’s a case in the supreme court since 2011, postponed again last year after pressure from the federal government, which means we continue to criminalise people who use drugs. Criminalisation is one of the worst forms of stigma. People in deprivation end up in these camps. There’s no official data about the number of people in these treatment centres. There’s no clear methodology. Often related to religious entities. No central body overseeing. The National Prevention Mechanism should be it; but they’re under pressure by government. It was discontinued last year but a judicial court has reopened it, albeit in fragility. Research reports human rights abuses in all centres. Forced and continued sedation, no religious freedom, involuntary detention, violence, threat of prison. This is all based on an idea that there’s a “crack epidemic”. The Federal government embargoed a survey on drug use that contradicted the rationale of the government. They use the data to report to UNODC, but internally, they keep saying there’s a drug epidemic. I would point out this is a key moment for drug policy in Brazil. We welcome all direct communication from international institutions to bring modern standards on data collection and treatment standards for people who use drugs.

Maria Plotko, Eurasian Harm Reduction Association:  In our countries, no criminalisation of use per se but criminalisation of possession, enforced particularly around treatment centres; so it very concretely creates a barrier. State-run centres, but usually detox only. In Russia, 26 regions out of 85 have centres. There are private centres but incredibly expensive. Religious ones but this is not for everyone. For women, it’s hard to advocate because we don’t have disaggregated data: `prisons, treatment centres, drug law offences, HIV, etc. We have also the problem that maternity hospitals and OST clinics do not work together so after giving birth, people do not have access to medication. During pregnancy, lack of access to OST. In Russia it’s banned, so no access at all. In Belarus, women receiving OST were deprived of parental rights. Cases of disclosure of HIV and drug dependence to authorities. No rehabilitation centres for women or women with children. Lack of assistance from police on gender based violence. Drug dependent women requesting help will be prosecuted. Shelters do not receive women with HIV or drug dependence status. We don’t have anything for women in our region.

Leigh Toomey, Vice Chair, UN Working Group on Arbitrary Detention: Time for questions.

Questions and answers

Representative of an organisation of people who use drugs, Greece: I come from a country with a long history of exclusion. For 4-5 years, no record of exclusion of people who use drugs. Your presentations reminded me of our hidden history. Greece used to exclude people with health issues and communists in islands. But they forgot to tell us that even before Second World War, people who use drugs. I have a little bit of experience of the way we are violated.

?: I’m from Brazil. I’m from the world federation of therapeutic communities. I agree with what you said. I was in Mexico and saw this reality. In Brazil, we can see what Henrique said. Just a point on therapeutic communities. A difficult situation for us is that the good organisations working legally with professional treatment that are real, because of the absence of laws, are confused with the therapeutic communities that are actually legitimate. Our organisation in Brazil, Latin America and the world also works hard to avoid this happening.

Steve Rolles: The country situation is depressing. It’s shocking to see the contradiction between OHCHR and WHO recommendations and the situation on the ground. How can UN organisations disseminate the right recommendations so that they are translated domestically. What’s the mechanisms to make the recommendations of best practice become a reality at the national level?
Annette Verster, World Health Organization: We develop guidance and how services should be. But we don’t have mechanisms to go into countries. We can only go if invited. We have presence in the Philippines, for instance, to name a country, and we try to make them see how we see evidence-based treatment and how detained people should actually benefit from community-based treatment.

?, Hungary: You didn’t mention the drugs used by these people, in Iran and Mexico. The problem in my country is that NPS coming from Eastern countries come and are used by the youth.
Corina Giacomello, EQUIS, Mexico: In terms of drugs, they all start with alcohol and tobacco, then in terms of illicit most cannabis. Crystal methamphetamine and heroin tend to mark their lives.
Alexander Söderholm, London School of Economics and Political Science: Their main drugs of use are heroin, methamphetamine and opium.


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