Forced rehabilitation of drug users in Indonesia not a solution

Indonesia is forcing people with drug dependence problems to go into rehab. joloei/www.shutterstock.com

Earlier this year, Indonesia executed 14 people, including Bali Nine duo Andrew Chan and Myuran Sukumaran, for drug offences. President Joko Widodo portrayed the executions as the ultimate weapon in an expansive “war on drugs” deployed to protect the country’s young generation from an alleged “national drug emergency”.

But his policy is harming the very people he claims he wishes to protect.

A problematic approach

Widodo’s tough approach does not only apply to drug traffickers. The Indonesian government, through its anti-drug agency, the National Narcotics Board (BNN), is pushing compulsory treatment for people with drug dependence. This coercive approach is jeopardising health gains made by existing harm reduction programs and is fertile ground for corruption and abuse.

BNN pledges to rehabilitate 100,000 drug users in 2015. They aim to double the numbers every year – to 200,000 in 2016 and 400,000 in the year after that.

But there aren’t enough problematic drug users in Indonesia to meet these targets. According to estimates by the Ministry of Health, Indonesia is home to about 74,000 injecting drug users. Only a fraction may choose drug treatment at any given time.

Some civil society groups working on the ground consider even this an overestimation. National Narcotics Board statistics claim a large number of crystal meth and cannabis users, but Indonesian academics argue these numbers have been derived using questionable methods.

There is a strong movement in Indonesia opposing the government’s tough approach. Activists in 15 cities in Indonesia last week joined a worldwide call for governments to end the counterproductive war on drugs.

Mandatory rehab = incarceration

Last year, seven government bodies in Indonesia, including BNN, the police, the Ministry of Health, and the Ministry of Social Affairs, signed a Memorandum of Understanding promoting rehabilitation for drug users. The memorandum appears to promote a more lenient approach to addressing drug use, calling for drug users to be “rehabilitated rather than incarcerated”.

But, in practice, BNN’s special drug eradication squad often seek out and forcibly detain suspected drug users; few people with drug dependence voluntarily choose treatment under the agency’s programs.

Indonesia currently has more than 400 addiction treatment facilities in hospitals, government narcotics clinics, and privately-run centres. But the country lacks formalised national best practice standards for addiction treatment. Options range from medical detox in hospitals and 12-step programs, to religious or spiritual centres that boast “curing” drug dependence using magic, prayer, beatings, and shackling drug users in cages with a ball and chain.

Most share the same goal: abstinence from drugs. And few independently evaluate the effectiveness of their programs.

To meet the 2015 target, the government is establishing additional drug rehabilitation centres inside 60 prisons and 30 police and military training academies.

It is hard to imagine how the substandard, overcrowded conditions and limited health facilities of existing prisons in Indonesia can address the nation’s drug woes. Critics claim sending people to rehabilitation centres in prison is simply another form of imprisonment or involuntary detention.

Corruption and abuse

When Indonesia amended its narcotics law in 2009, there was hope for a more balanced response to drugs. The revised law effectively decriminalised possession of small amounts of drugs for personal use by providing judges with the discretion to divert drug users to treatment programs instead of prison. But, in practice, the criminalisation of drug use continued.

Some authorities use the new legal provisions to extract heftier prices from well-off drug users, and downgrade the offence they were charged with. As of May 2015, 36% of prisoners in the country’s 427 overcrowded detention facilities are serving time for drug use.

Working together with the Indonesian Drug Users Network, I am documenting a host of coercive and abusive measures carried out by law enforcement in the name of rehabilitation.

Health workers in Jakarta have reported an increase in the number of drug raids since January 2015 in known drug-use hot spots, but also in apartment buildings, schools, and community health clinics.

We found cases of forced urine testing, corruption, extortion, intimidation, and confidentiality breaches. Officers photograph suspected drug users against their will. They offer money in exchange for snitching on friends and family members who may use drugs. They demand access to private client records at methadone substitution clinics and other organisations working with drug users.

The government should seriously reconsider this approach, as studies have shown that criminalisation and punitive law enforcement approaches can lead to higher drug-related criminality and increased risk of contracting HIV and hepatitis C, among other unintended social and economic costs.

Compulsory treatment is ineffective

Indonesia’s coercive measures are at odds with a broader tendency in Asia to move away from compulsory treatment and transition toward voluntary, scientifically and medically appropriate approaches to managing drug use.

Compulsory treatment and rehabilitation is costly and ineffective in addressing drug issues; relapse rates are high. There is no evidence that compulsory treatment leads to positive health outcomes among drug users or that it has any effect on drug use rates.

Instead, compulsory treatment in countries such as Cambodia, China, Malaysia, Myanmar, Philippines, Thailand and Vietnam has led to increased HIV risks, added stigma and discrimination against drug users, and human rights violations.

In July 2012, the United Nations issued a Joint Statement calling for the closure of compulsory drug detention and rehabilitation centres. They called governments to adopt “voluntary, evidence-informed and rights-based health and social services in the community”.

Alternatives to compulsory treatment

Harm reduction interventions such as needle syringe programs and methadone maintenance therapy are some of the world’s most effective and affordable treatments available. If President Widodo is serious about managing Indonesia’s drug problem, he should urgently scale up these proven strategies.

Methadone maintenance therapy reduces heroin use, HIV transmission, criminal activity and risk of drug-related death. The expansion of such programs in Indonesia has helped reduce HIV rates among injectors from 42% in 2011 to 36% in 2013, bringing thousands of drug users closer to health and support services.

Indonesia is also home to some of Asia’s most successful voluntary, community-based treatment programs for drug users. These include Rumah Cemara and Rumah Singgah PEKA, which are currently in the process of being documented as best practice treatment models by the United Nations Office on Drugs and Crime (UNODC).

These and more than a dozen programs like them are based in non-government organisations, often run by former drug users and offering a menu of evidence-based harm reduction and treatment options from which clients can choose.

The outcome isn’t always abstinence from drugs, but an improvement in the client’s social function, overall health, productivity, reduction in risky drug use patterns, and personal goals.

From a public health perspective, drug use is best portrayed as existing on a spectrum from beneficial to problematic. The majority of people who try drugs or use them occasionally never develop dependence or problematic use patterns.

Leaders who want to support those dealing with drug dependence should listen to their needs and support them with strategies that work, rather than instituting policies that punish them.