Condemned to Death

Condemned to Death

Thanks to the US-led drug war, AIDS is exploding among injection drug users.


In addition to the obligatory red ribbons, the logo for the XV International AIDS Conference features three Asian elephants raising their trunks as if in welcome. The world’s most important gathering of AIDS specialists will be held this July in Bangkok, a location chosen not only because Asia is thought to be the site of the next big wave of HIV infections but because Thailand is one of only a few developing countries that have thus far seemed able to control them.

International experts have hailed Thailand’s 100 percent condom program, which in the 1990s distributed some 60 million condoms free to sex establishments, engaged brothel owners and government officials alike to make sure they were used and helped bring down rates of HIV and sexually transmitted infections as much as fourfold. Thailand is also the first developing country to create a functional program to stop mother-to-child HIV transmission, providing free prenatal care and preventive medication to more than three-quarters of pregnant women testing positive for HIV. Last June Kofi Annan’s praise of Thailand was one of the few bright spots in an otherwise grim report to the UN General Assembly on lack of global progress against AIDS.

Yet the elephant–icon of long memory–is an ironic symbol for the AIDS conference in one respect. Conference organizers and UN officials alike seem to want to forget that, to the group at highest risk for HIV across Asia–injection drug users–what Thailand offers looks less like innovative AIDS prevention than old-fashioned, barrel-of-the-gun repression. In February 2003 the governing Thai Rak Thai (Thais Love Thais) party launched an all-out war on drugs that has included forced urine testing at nightclubs and bars, arrest quotas and mass roundups of alleged dealers and addicts.

While ostensibly focusing on dealers of “ya-baa” (“crazy drug”), the methamphetamine made in cottage labs across Thailand and flowing in vast quantities from nearby Myanmar, the campaign has forced hundreds of thousands of Thais who are on government blacklists, including many with no history of drug use at all, to report to the police. “Panic is so strong that mothers who have never used any drug are reporting to treatment centers to clear the family name,” says Paisan Suwannawong of the Thai Drug Users’ Network. Less than three months after the crackdown began, more than 43,000 “drug traffickers” had reportedly been imprisoned and as many as 230,000 Thais interned in military-run “treatment” centers, where they were drilled in boot-camp-style exercises and made to chant antidrug propaganda. Even more ominously, nearly 2,600 men, women and children–most of them ethnic minorities from the north–have been gunned down during the crackdown. Government officials insist that all but a handful of the deaths are “cut off” killings perpetrated by drug dealers trying to prevent incriminating testimony. Human rights observers say the murders–accomplished with the neat efficiency of professional hit men, sometimes as victims are in handcuffs or returning from police interrogation–look more like systematic extrajudicial executions.

Prime Minister and former police officer Thaksin Shinawatra–who last year enjoyed rising popularity ratings, the fastest-growing stock market in Asia and a spate of visits with President Bush unblemished by public discussion of human rights violations–has declared the war on drugs a “beautiful success.” Not surprisingly, however, the crackdown’s effect on programs serving drug users, including HIV prevention and research efforts, has been immediate and ugly. A study led by researchers at Chiang Mai University last June found that more than a third of Thai drug users going to rehabilitation clinics had stopped attending, with many likely to have returned to injection and high risk of HIV infection. In the north, AIDS researchers working with hill tribes pulled their teams for fear of being caught in the crossfire. Paisan of the Thai Drug Users’ Network sees the crackdown as the latest in a series of HIV-prevention missteps that have included cancellation of the country’s only needle-exchange program and failure to implement countrywide methadone maintenance programs in spite of clear evidence of their efficacy. As a result, while rates of HIV have fallen among Thai sex workers, they have been climbing steadily among injection drug users.

Local drug wars have long been bound up with global markets. America’s first antinarcotics legislation, the Harrison Act of 1914, was passed in part to curry favor with China by demonstrating US opposition to opium, thus edging Britain out of competition for lucrative trade. Today, countries either produce zero-tolerance policies for the US State Department as proof of fitness for duty in the open markets, or risk exclusion from them. From 1994 to 1998, for example, Nigeria was “decertified” as a recipient of US aid for failure to take an active-enough role in drug control. Thailand, by contrast–hailed by President Bush as a “partner in the war against terror,” an all-purpose designation that serves in current parlance to invoke Thailand’s drug-war efforts, its contribution of soldiers to the occupation of Iraq and government efforts to quell an uprising in the country’s mostly Muslim south–received special non-NATO ally status from the United States this past October, entitling it to foreign trade concessions and discounts on military matériel.

Meanwhile, wholesale assaults on drug users have become a part of the political landscape across Asia and the former Soviet Union, particularly since heroin and methamphetamine are among the “goods” circulating with increasing speed across the newly opened borders, recently constructed highways and new free-trade zones characteristic of post-cold war economies. The Vietnamese recently intensified a decade-long “social evils” campaign against drug use, forcing 25,000 drug users in Ho Chi Minh City into treatment since late 2001 and extending to five years the period of forced labor they term “rehabilitation.” In China, Human Rights Watch has documented mass roundups in Yunnan province, with drug users forced to work making fake gems or batik scarves for Yunnan’s burgeoning tourist trade. In Malaysia, former Prime Minister Mahathir Mohamad launched a “social evils” campaign against drugs last July. This effort built on repressive policies of Malaysia’s recent past, including mandatory flogging and imprisonment for possession of any amount of any illicit drug, and granting police the ability to detain suspects for two weeks, administer drug tests and imprison anyone showing past evidence of drug use.

What is relatively new, and exacerbated dangerously by the global drug war, is AIDS. Particularly where economic “opening” has translated into little more than the closure of local industries and an end to state-supported healthcare, people from St. Petersburg to Tajikistan to China have turned to underground economies: smuggling, blood or organ donation, the sale of drugs or sex. STD and HIV epidemics have followed, in turn accelerated by the penchant of governments for criminal enforcement. “Call it the mixing bowl effect,” says Chris Beyrer, a Johns Hopkins epidemiologist whose work has traced the ways that HIV outbreaks follow drug trafficking patterns. “Force uninfected and infected people together in institutions where drug use and sex continue, make condoms and sterile injection equipment impossible to obtain, and release those who are newly infected back into a society that punishes admission of drug use with stigmatization and reincarceration.”

Indeed, outside Africa, national and international policy toward drug users will play a critical role in determining the course of the HIV epidemic in the next decade. Needle-borne HIV infections spread faster than sexually transmitted ones, and Eastern Europe and Asia are already facing injection-driven epidemics of unprecedented scale and scope. Malaysia and Vietnam have registered more than 55,000 and 75,000 cases of HIV, respectively, with the majority of cases in both countries among injection drug users and the actual numbers of those infected thought to be much higher. The Chinese government–though likely to be vastly underestimating the scope of those infected through blood donation schemes in the center of the country–already acknowledges that 1 million Chinese are HIV-infected, more than 60 percent of them injection drug users. In Russia, 1 million people–more than in all of North America–are estimated to have HIV. Virtually all were infected in the past eight years. Three-quarters are under 30. More than 90 percent shoot drugs.

The good news is that injection-driven epidemics are relatively easy to contain. Participants in needle-exchange programs show none of the ambivalence associated with behavioral initiatives to increase condom use: Almost no drug user chooses to share needles if offered another option. Ongoing treatment with methadone, widely tested in developing and industrialized countries alike, has been shown to reduce both injection and drug-related crime. More broadly, researchers evaluating the full spectrum of efforts to prevent HIV and other harms among drug users–which includes peer education, syringe exchange and safer injection rooms, methadone maintenance and overdose prevention–have demonstrated positive outcomes in trials from Australia to Belarus.

The bad news is that evidence of effectiveness has so far proven no match for ideology. Public health efforts to offer drug users options other than abstinence, whether in the United States, Asia or the former Soviet Union, have frequently taken a back seat to criminal enforcement campaigns or languished for years in perpetual pilot-program status.

With nearly 2 billion people in countries with skyrocketing, injection-driven HIV epidemics, one might expect coordinated, emergency action at the organization spearheading international control of both drugs and HIV: the United Nations. The declaration emerging from the 2001 UN General Assembly Special Session on HIV/AIDS (known by the unfortunate acronym UNGASS) did include–over the objections of the United States, Russia and a number of Muslim states–passing mention of the importance of clean needles and other measures to reduce drug-related harm. The World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) both regularly affirm the importance of a full range of HIV prevention strategies, including the needle-exchange and methadone programs that have controlled injection-driven HIV transmission in Australia and Western Europe. No UN entity, however, has worked with national governments and international donors to bring a harm-reduction program to national scale in countries where injectors are the majority of those with HIV. Methadone remains on the UN’s list of the most dangerous, tightly controlled substances. In the rhetorical balancing act by which the UN stakes out a safe position on controversial issues, resolutions for harm-reduction measures have been countered by others emphasizing criminal enforcement. For every UNAIDS advocate who points to the 2001 UNGASS, there are multiple drug-control proponents who invoke the promises made at the 1998 special session convened by the United Nations Office for Drug Control and Crime Prevention under the motto “A Drug-Free World, We Can Do It!”

The UN measures with real teeth–legally binding for the 168 countries that have signed them, including all those with injection-driven HIV epidemics–remain the drug-control protocols of 1961, 1971 and 1988. Known collectively as the UN drug control conventions, these classify more than 200 substances based on danger of abuse, dependence and medical benefit; mandate that narcotics and psychotropics be used only for medical and scientific purposes; and require that countries criminalize possession or manufacture of controlled substances for personal use. In addition to the UN Office on Drugs and Crime (UNODC), which implements UN drug programs on the ground, the conventions are backed up by a substantial political apparatus: the Commission on Narcotic Drugs (CND), which sets UN drug policy, and the International Narcotics Control Board (INCB), which monitors international compliance.

In theory the conventions, which do not specify penalties for drugs or even require that the laws against possession be enforced, are flexible. But in the drug war, as in other conflicts, the United States has expended significant energy to muscle the UN into endorsement of its belief that the only strong intervention is a strongly punitive one. Drug politics makes strange bedfellows, and the coalition of the prohibitionist willing in the drug war includes Russia, several Muslim states, Sweden and Japan. Since UN drug control is almost entirely dependent on donations from member states, the United States–a major donor and a global superpower–has historically had great success in pushing the UN drug-control machinery to reproduce its own domestic schizophrenia, in which scientists emphasize the importance of evidence-based interventions even as they avoid supporting the needle-exchange and methadone-maintenance programs most clearly demonstrated to prevent HIV.

“It was never in writing,” says Cindy Fazey, who worked for eight years in the UN drug control system and served from 1990 to 1995 as chief of drug-demand reduction. “But as you’re drafting a declaration or planning a program, you’d get a call from a US official saying, ‘If you include this phrase, we not only won’t support it, but we’ll make sure it doesn’t pass.'” Fazey says meetings of CND donors she attended often included a representative from the US State Department’s Bureau of International Narcotic Matters who had no official role but was actively involved in the proceedings. “He would go from delegation to delegation,” Fazey says. “And in the end, everyone understood–no needle exchange, no harm reduction and certainly nothing like prescription of heroin.”

CND representatives are accountable to their governments, and recent CND sessions have included resolutions acknowledging the value of sterile injection equipment and spirited debate between US abstentionists and Europeans pressing to remove legal obstacles to clean-needle programs or methadone treatment. UNODC has also begun in recent years to provide limited support to needle-exchange and substitution-treatment programs, citing the need for a “harmonized” approach at the UN. By contrast, the members of the INCB have operated as a hard-line judiciary accountable only to themselves. Including Iranian psychiatrist Hamid Ghodse, longtime Nigerian UN drug-control consultant Philip Emafo and ancient Russian pharmacologist Edouard Babayan, the voices that have historically dominated the INCB make CND meetings sound like a High Times convention. “We are talking about the dinosaurs of UN drug control, heavily invested in the most rigid interpretation of the conventions,” says Martin Jelsma, a drug policy expert at the Transnational Institute, a Dutch think tank.

The dinosaurs bite: They have lambasted reduction of criminal penalties for cannabis in Spain, criticized medical journals for publishing studies showing the therapeutic benefit of marijuana and even suggested that politicians who campaign for more liberal drug policy might be prosecutable for violating convention restrictions against inciting drug use. The INCB response to what it terms “the crusade for harm reduction” has often been to equate it, erroneously, with drug legalization, and then to condemn it: It has sharply criticized medical prescription of heroin in Switzerland, cowed Denmark into tabling plans for safer injection rooms and threatened to revoke Australia’s license to cultivate opium for medical purposes upon learning of plans for a safer injection room in New South Wales.

It is apparently of secondary importance whether this pressure has any legal basis. In September 2002 the INCB asked UNODC legal experts to consider whether harm-reduction measures were consonant with the UN drug conventions. The UNODC lawyers noted three important features of the conventions that could justify methadone-maintenance treatment, safer injection rooms and provision of sterile syringes. First, all of these could be seen as medical treatment, permissible under the conventions. Second, the conventions urge reduction of drug use and its adverse consequences, which clearly include HIV, thus potentially justifying measures to reduce infection. Finally, the conventions prohibit intentional incitement to or encouragement of drug use, and none of these harm-reduction measures could be said to be performed with the intent of encouraging drug use. “When the findings did not arrive at the desired conclusions, the INCB didn’t want to release them,” says Jelsma. Though the document was leaked, the board was unyielding. Not three months later, in an official UN publication, INCB president Philip Emafo declared that “giving out of needles” amounted to inciting drug abuse, and was contrary to the conventions.

Whether cause or convenient excuse, the UN conventions and related drug-control efforts are routinely invoked by countries seeking to explain why they fail to offer drug users anything but prison or forced abstinence. A UN survey of seven Asian countries with injection-driven epidemics noted that many governments do not support methadone, in the belief that it would contravene the UN conventions. In China, the UN’s International Day Against Drug Abuse has become an annual occasion for gatherings in public stadiums that include virulent speeches by government officials, the public burning of confiscated drugs in enormous caldrons and condemnation of drug dealers to death to chants of “kill, kill” from the audience. A visit by Thai representatives to UN drug control director Antonio Maria Costa at the height of the Thai drug war yielded headlines in Bangkok trumpeting UN approval for the Thai approach. Russian Minister of Interior Affairs Boris Gryzlov recently told the State Duma that “total prohibition” of illicit drug use was “not the [government’s] own initiative, but rather a responsibility to implement the UN Drug Conventions of 1961, 1971 and 1988.”

It is in Russia that the price of the global drug war may prove costliest. Heroin continues to flood the country from Afghanistan, and for four years in a row the HIV epidemic there has grown faster than anywhere in the world. While groups like George Soros’s Open Society Institute and Médecins Sans Frontières have supported needle-exchange programs, none of the national government’s meager, $4 million AIDS budget is targeted for provision of sterile syringes. The health ministry’s HIV prevention unit is reported to have a full-time staff of three. Methadone remains against the law throughout the country, and until recently it was illegal to describe drug use in any but negative terms. A government drug education program, Coma, offers television viewers weekly insights such as the suggestion that drug users be sent to concentration camps to keep them away from children. “It is one of the clearest examples of hate speech I have ever heard,” says Tatiana Lokshina, director of the Moscow Helsinki Group, a human rights organization.

In 1996, using a chart drafted by INCB member Edouard Babayan, officials revised downward by as much as a factor of fifty the amounts of illicit drugs punishable by imprisonment. Sidestepping the fact that Russian law did not punish drug use per se, the new chart classified even tiny amounts of drugs as either “large” or “extra large,” making everyone liable for the more serious crime of large-scale possession. “Even the dust on an envelope that contained heroin or half a marijuana cigarette was suddenly punishable by years in prison,” says Lokshina. There were 100,000 convictions in the first year following passage of new penalties, and the number of those imprisoned for drugs increased fivefold between 1997 and 2000. Pretrial detention centers–where prisoners often remained for months–were so full that inmates had to sleep in shifts, with some fainting from lack of oxygen.

“We call it the American syndrome,” says Lev Levinson, a former Duma staffer and policy expert working to reform the drug laws, “when the response to the danger of drug use becomes more dangerous than the drug use itself.” Even after sharp restriction of pretrial detention and repeated amnesties to reduce prison overcrowding, Levinson says, as many as 20 percent of Russia’s more than 800,000 prisoners, and 40 percent of all Russian women in prison, are there on drug charges. For many, imprisonment includes risk of infection with the deadly, multiple-drug-resistant tuberculosis now rampant in the Russian penal system, as well as continued exposure to drugs and HIV. A 2000 study of drug users in seven Russian prisons found that almost one in seven injected for the first time while incarcerated. The Moscow Helsinki Group reports that rates of HIV among those in prison have increased by 2,000 percent since drug recriminalization.

A handful of Russian provincial and municipal governments have put programs in place to offer education on safer injection and safer sex. Moscow, however, isn’t buying. Last October sixteen members of the City Duma wrote to Senate majority leader Bill Frist and Speaker of the House Dennis Hastert to object to US-funded programs that distribute condoms to “drug-addicted prostitutes.” In a statement that neatly captures how easily American prohibitions at home are twisted to undermine HIV prevention abroad, they claimed that US funding of “harm reduction” efforts such as sex education and condom distribution were endangering Russia’s children and the country’s moral standards. “If a policy is not acceptable in America,” they concluded, “please do not export it to us.”

Global policy on illicit drugs is Janus-faced, constantly shifting between criminal enforcement and public health. In Moscow, Levinson and his fellow campaigners have won parliamentary approval for less punitive drug-sentencing guidelines, and Babayan’s infamous drug-penalty table is set to be revised by mid-May. At the same time, the Moscow Duma has proposed mandatory drug and HIV testing for the homeless, sex workers and other high-risk groups in the city, and the State Drug Control Committee has urged criminal action against those who advocate for harm reduction. In Thailand, Prime Minister Thaksin declared victory in the war on drugs in honor of the King’s birthday this past December. He renewed it in March, dismissing as “annoying” a February State Department report citing Thai human rights violations, and initiating a new round of police raids and forced drug testing. International AIDS Conference organizers, though, are meeting with the Thai activists to insure a focus on the human rights of drug users, and the Global Fund to Fight AIDS, Tuberculosis and Malaria recently awarded the Thai Drug Users’ Network a $1 million grant. Made outside of Thailand’s official country coordinating mechanism, the award recognized the group’s claim that drug users were a stigmatized minority unlikely to be addressed fairly in government AIDS efforts.

The most important change in global drug-war policy, however, may come as a dividend of conventional global conflicts. In a rebuke observers suspect had less to do with drugs than with the Bush Administration’s highhandedness on issues like the Kyoto Protocol and global arms-control efforts, the UN voted the US representatives off both the Human Rights Commission and the International Narcotics Control Board in 2001. The United States subsequently increased its pledges to UNODC by 45 percent, becoming the single largest supporter of UN drug-control efforts, and successfully fielded a candidate to replace a departing INCB delegate from Peru. But given growing impatience with American unilateralism, money may no longer be able to buy US drug warriors love. This year’s INCB report, released in March, suggested that neither syringe exchange nor substitution treatment violated UN conventions when offered as part of a wider effort to reduce demand for drugs, and six INCB delegates will potentially make way for new nominees next year. “Europe is going its own way on illicit drug policy,” says Cindy Fazey, pointing to the opening of safer injection rooms, decriminalizing of cannabis and return to heroin prescription in a growing number of EU countries. “It is happening quietly but is likely to be irrevocable.”

The question is how long reform at the UN, if it happens, will take to change conditions for drug users in the countries where the AIDS epidemic is growing fastest. American intelligence reports now predict 15 million HIV cases in China, and 8 million in Russia, by 2010. Some 1,300 new HIV cases are diagnosed each month in Vietnam. Ukraine, with 69 percent of an estimated 400,000 HIV cases among drug users, and Estonia–where 85 percent of HIV cases are drug users–are now tied for the highest HIV prevalence in Europe. Injection drug users are the majority of cases in all the Baltic states, the Central Asian republics, Nepal, Indonesia, Iran, Afghanistan and Pakistan. “Drug use has proved to be the key factor in establishing HIV epidemics across a landmass that extends from Spain to the Sakhalin Islands, and from Siberia to Bali,” says Chris Beyrer. One can only hope that when the United States wakes up to the need for sound drug and HIV policies, we won’t have created another Africa in Asia.

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