Locking, chaining, and other punishments in the name of treatment may be more common than we know in Peru. The agency responsible for drug prevention and treatment—the Comision National para el Desarrollo y Vida sin Drogas, or DEVIDA–notes that of 222 “rehabilitation” facilities in the country, only 20 percent have all the necessary licenses and required medical staff.  There are an estimated 700 “treatment” slots for an estimated 100,000 people in need. The Peruvian facilities are private entities—a distinction from the government-run labor camps masquerading as drug treatment centers in Vietnam and China—but they are equally deadly. As the fires and deaths show, being sent to a Peruvian drug treatment center can be the equivalent of a death sentence.

In certain legal respects, the comparison to a death sentence may even be a bit generous. After all, people charged with a capital crime are entitled to a trial and legal defense, usually at the government’s expense. Peru’s Law 29737, which is applied to detain people who use drugs or who have intellectual disabilities, declares them “incompetent” to exercise their right to due process. This law is contrary to the UN Convention on the Rights of People with Disabilities, which Peru ratified, and the Standard Minimum Rules for the Treatment of Detainees, among other standards.

National and international experts have made it clear that prolonged detention, chaining, beating, and delivery of moral lectures rather than evidence-based treatment is both ethically unacceptable, and medically harmful. DEVIDA itself has published a document on best practices that includes examples of two evidence-based treatment centers. How many more deaths by burning, or years wasted in useless detention, must Peruvians suffer before the government repeals Law 29737 and invests in real solutions?

This call for closure of drug detention camps comes after years of horrifying reports of abuses in these facilities. In China, authorities estimate that there are 216,000 drug users detained in these camps—a reduced number from past years, but still far too many. Upon testing positive for drug use, these men and women are detained for up to five years and forced to work without pay as part of their “treatment.” In Vietnam, a recent estimate placed the number of detainees in forced labor camps at 35,000. Cambodia  and Laos also use compulsory drug detention, without medical assessment or right of appeal for those locked up.  Children are locked up too.

People who use drugs in such facilities have been beaten, starved, forced to work in the service of private companies, systematically humiliated, and brutally punished when they tried to escape. Nonetheless, governments continue to describe these detention camps as treatment and rehabilitation centers, and aid agencies have been hesitant to directly challenge this characterization. In some cases, donors have even worked to “build capacity” of center staff in drug treatment methods, as if staff who beat and torture detainees in the morning could be effective counselors in the afternoon. UN representatives have privately condemned these abuses, but in the past felt no ability to publicly confront governments on these practices. “We all know these places are concentration camps,” one UN official confided during our coffee together. “But really, what do you expect us to do?”

The joint UN statement offers an answer—one that should be heeded and replicated by donors like the U.S. and Australia who also fund HIV and drug-dependence programs in countries where such centers operate. Declaring that the centers have no place in civilized society and should be closed is a good start.

Next, of course, is the hardest part—work by the UN, international donors, non-governmental organizations, and governments themselves to move to voluntary, community-based treatment for those who need it, thus changing the UN recommendation to a reality.

Milloy's analysis showed that incarceration kickstarted  viral replication among patients who had previously had their HIV under control. The findings make the study one of a number of must-reads on how prison practices not only impact the health of inmates but communities at large. A 2008 analysis by Stuckler et al of 26 countries in Central Asia and Eastern Europe graphically captured the way that higher rates of inprisonment correlated with higher rates of drug resistant tuberculosis overall (click here to see the graph). Epidemiologist Ernie Drucker's recent book Plague of Prisons looks at incarceration in the U.S. in terms usually used for disease outbreaks. As Drucker points out, there has been an epidemic of mass incarceration in the U.S., with associated destruction of social supports and thousands of productive years lost.

In an editorial in JAIDS, my colleagues and I argue that studies like the one by Milloy force us to look critically at the cost of incarceration and at conventional wisdom about HIV treatment failure. It has been common, for example, to suggest that drug users are less likely to adhere to HIV treatment. But have we been asking the right questions? In Milloy's analysis, not incarcerating patients would have resulted in as much as a 40 percent increase in successful HIV treatment. It was not injection of heroin or bingeing on crack, but the social response to those acts, that determined whether people's HIV infection remained under control.

It's an important reminder to those who think that an iron fist (and steel bars) are the best response to combat drug use. Instead of pointing fingers at individuals, we should take a closer look at the social structures that lead to poor health outcomes.

The story is unfortunately one of many tragic accounts from so-called drug treatment centers offering harsh discipline, bodily privations, and lectures about moral weakness to those who actually need medication and counseling to ease their discomfort. Death by burning is also strikingly common—in Russia, for example, 43 young, mostly HIV-positive women (and two nurses) died in 2006 when staff ran away from a substance abuse hospital during a fire, leaving the patients to struggle against barred windows and locked doors. Several years later, another fire and more deaths occurred in a closed drug treatment facility in Kazakhstan. The logic of “treatment” facilities that require their patients to be locked in against their will goes unquestioned in these incidents, which are dismissed as individual tragedies. One hopes that the Peru fire will be the last, and more generally that national authorities in that country and in others will take steps to scrutinize laws and practices that justify locking drug users up and abusing them in the name of making them better.

We at the International Harm Reduction Development Program recently published Treated with Cruelty, which includes multiple personal accounts of abuses in the name of drug treatment and rehabilitation, and an analysis of the human rights implications. From Mexico to China, Russia to Cambodia, the stories—of flogging therapy, starvation, chains, and slave labor—offer different windows onto the same terrible theme: that “tough love” is enough to cure drug addiction, and that civilian casualties and years of confinement are regarded as an unfortunate but necessary part of the battle. This volume was part of the Campaign to Stop Torture in Health Care, named to draw attention to the fact that intentional infliction of cruel, inhuman, and degrading treatment and suffering are more common than we would like to believe in the health care field, and that these practices are illegal, abhorrent, and can be stopped.

Even the fire at Christ is Love will no doubt seem fitting to some who believe that the wages of sin are death. Those with such beliefs, however—and indeed, all those supporting drug treatment facilities that rely on beating, starving, humiliation, and barred doors—have no place in the world’s approach to drug treatment.  One look at the horrible pictures at Christ is Love reminds us that the current standards are too low, and that it is the system, rather than those who are drug dependent and seeking help, that need to be the priority for change.

Researchers also didn't detail whether follow-up was done to monitor for post-treatment opioid overdose among participants. As I and other co-authors argued in a commentary linked to the Lancet article, the U.S. Food and Drug Administration, which approved the efficacy of the medicine for opioid users based on this one trial in Russia, should have demanded more data and higher ethical standards before giving marketers the green light.

While use of injectable naltrexone in opioid dependence is new, the FDA’s own Adverse Event Reporting System has recorded 51 fatal reports associated with injectable naltrexone since it was approved for alcoholism dependence—a magnitude of unlabeled adverse events that in the past has triggered black-box warnings for other drugs. Further, a review of 13 trials on opioid substitution treatment options in Australia found that patients on oral naltrexone were three times more likely to experience heroin overdose than those on opioid-agonist medications, such as methadone and buprenorphine. When a patient had stopped taking naltrexone, the risk of overdose rose eightfold.

In light of such evidence, the FDA must explain why it required just one study before declaring this medication safe to use.

Also left unanswered is how the study’s authors deemed it ethical to expose some trial participants to placebo. In 1964, the World Medical Association issued guidelines for ethical research known as the Helsinki Declaration. One of the declaration's key principles holds that use of a placebo in clinical trials is unjustified when there is a demonstrated standard of treatment.

In the case of addiction to heroin and other opioids, earlier studies have shown the effectiveness of the medicines methadone and buprenorphine, and demonstrated the perils of making clinical trial participants go without. Inexplicably, investigators chose to conduct the trial in Russia, where authorities outlaw use of methadone or buprenorphine. Taking Russian data and using it to seek marketing approval in the U.S. represents a particularly insidious and ethically questionable “bait and switch.”

Injectable naltrexone is now being marketed to heroin addicts at as much as a whopping $1,100 per month. One hopes that the rush to market does not mean that desperate patients end up paying an even steeper, fatal price.

This is not Malaysia’s problem alone.  In Ukraine, authorities tightened the drug control policies last month, announcing that anyone found with drug residue in a used syringe would be sent to prison, and leaving needle exchange programs wondering whether they are vulnerable to prosecution. The Transnational Institute and the Washington Institute on Latin America released a report today finding that prison systems in eight Latin American countries had been swamped by low-level drug offenders, while drug traffickers continued to go free.  In China, where the government has been rightly saluted for increasing the availability of the medication methadone, more than three times as many people are in drug detention centers where they’re offered the “treatment” of forced labor for 16 hours a day.  In Vietnam, there are more than 10 times as many people in punitive forced labor facilities as on methadone.

The medical literature is full of studies that have sought to answer the question of how to increase access to HIV prevention and treatment for injection drug users.  Does peer-based needle exchange work?  If patients get preloaded pillboxes or work with case managers, will they take more of their HIV medicines? Does prescription of medicines like methadone or buprenorphine to reduce drug cravings also improve ability to get and stay on antiretroviral treatment?  The answer to all of these has turned out to be yes, though the discussion today in Malaysia and the reports from Ukraine and Latin America remind us that all this attention to the individual may be missing the real cause of treatment interruptions.  Too often, we blame patients for system failures—particularly failures of a law enforcement system that treats people like illicit drugs, as something to be controlled and contained, rather than as people deserving of dignity, treatment, and care.

Change is possible.  In Malaysia, the expert meeting was attended also by the Deputy Director of Malaysia’s Anti-Drugs Agency, Dr. Professor Mahmood Nazar, who announced that Malaysia has shifted resources from compulsory drug detention to voluntary drug treatment.  Another expert, Dr. Steffanie Strathdee, produced findings suggesting that in Odessa, Ukraine, up to one fifth of HIV infections would be eliminated if we prevented police beatings (by extension, we can assume the same holds true in other regions with high rates of police violence against people who use drugs).

In multiple countries in Eastern Europe and Central Asia, the Open Society Public Health Program is supporting efforts to integrate lawyers with harm reduction programs.  For people who use drugs, access to justice may be as crucial as a condom, a clean needle, or antiretroviral treatment.

This month, the UN’s reference group on injection drug use and HIV, which includes experts from more than 26 countries, issued its consensus statement on key issues for action. Among them was the clear call for an end to imprisonment for people who have committed no other crime than drug use or possession of drugs for personal use.  Drug detention and prison, where HIV medicines and needles are rarely available and where risk behavior and disease-producing conditions are common, are bad for public health.  The sooner national governments take up the expert consensus and get police out of health care and drug users out of detention, the sooner universal access to HIV prevention and treatment for people who use drugs will move from aspirational goal to achievable reality.

As in Africa, where patients have used cell phones and Google maps to document empty pharmacy shelves, Russian activist efforts have featured a combination of new media and old-fashioned street theater. Patients experiencing treatment problems email to a central website run by the Russian group International Treatment Preparedness Coalition (ITPC.ru), an Open Society Foundations grantee, whose site has page after page of entries detailing medication shortages, doling out of expired drugs, or regimen changes due to supply interruption.

Heads turned in Red Square in September when "nurses," whose blonde wigs evoked Russian health minister Tatyana Golikova, led a colleague dressed as a bear (symbol of Russia, equivalent to America's  eagle) around on a leash (view a photo from Russian citizen journalism site Demotix). While interpretations varied—some commentators said the action symbolized the need for the health authorities to leash the uncurbed appetites of Russian businessmen, while others saw a comment on how  the health ministry was leading Russia to disaster—the action, followed by another where activists chained themselves in front of the health ministry, got the attention of the press. And of the authorities, who continue to insist that the Russian AIDS treatment system is doing just fine.

Government representatives may soon have to tell that to the judge, and to human rights specialists in Geneva. In Russia, people with HIV have brought nine different lawsuits against AIDS centers that have stopped or changed medical treatments for nonmedical reasons. This week, a complaint was filed with the United Nations Special Rapporteur on Health.

While stock-outs are the most pressing issue, community advocates have also revealed another pernicious problem with Russian AIDS treatment system: the medical commission. According a report, "ARV in Russia: Problems and Recommendations for Improvement" [pdf], drawn from interviews in 19 cities surveyed by a network of community correspondents calling themselves SIMONA+, any patient seeking HIV treatment has to have medical records reviewed by a commission of multiple doctors, most or all of whom have never seen the patient in question.

Many of these commissions require multiple and unnecessary tests and do not consider the opinions of the social workers most familiar with the patient's likelihood of sticking to their medical regimen. In more than half, the commissions use drug use as a criterion for denying treatment. While Russia has come a long way since the bad old days when even AIDS doctors in cosmopolitan centers like St. Petersburg decided that drug users were socially unproductive and so undeserving of treatment, mechanisms like the treatment commissions subject drug users to a softer, but no less deadly, form of bigotry and treatment denial.

Prime Minister Vladimir Putin has sought to redeem Russia from perceptions of moral and financial backwardness on HIV, pledging universal treatment for all people with AIDS in Russia, and returning the monies received from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. These promises, however, will remain hollow so long as old models like centralized, inflexible procurement of medication, and commissions that deny treatment to active drug users, remain in place. The number of Russians living with HIV continues to grow steadily, according to the UNAIDS 2010 Global Report, and  some 70 percent of Russian HIV infections are among those with a history of intravenous drug use. Instead of universal access, what Russia currently offers is an AIDS system unavailable to the majority in need.

In China, Vietnam, and Cambodia, detainees in these centers report being beaten by guards, sexually abused, and starved. In China and Vietnam, they are forced to work without pay, often in the service of private companies that contract for slave labor with the centers, with severe beatings if you don’t meet your work quota.  Even if you enter voluntarily you are beaten within an inch of your life if you try to escape before the end of your term, and terms have been progressively extended.  Now, China interns you for up to two years for a positive urine test, and in Vietnam it can be up to four.

Every center in Vietnam has a “punishment room”—by law.  Infractions like smoking a cigarette or drinking tea may land you in this room for weeks at a time. In here, you may be forced to hang for hours by one or both arms, made to kneel for hours on sharp objects, forced to squat in water in a room that is too small to stand up in, or just left alone for weeks  in a one meter by one meter room that is too small to lie down in.

Funders and those who implement their programs are left with a very real ethical and programmatic conundrum. If people are starving in a concentration camp, do you go in and serve them food? How about medicines for those with HIV? If you do decide to go in, how do you talk and think about it to ensure that you’re not just working to perpetuate a system that is illegal, immoral, and in fact only impedes the public health goals you are supposed to be supporting? As one of the ethicists at the meeting described, you want to avoid what philosopher Avishai Margolit calls the “rotten compromise”—working to reach common understanding with a system so fundamentally organized around humiliation or degradation that a collaboration is ethically unworkable.

The U.S. government-funded implementers working in or around the organizations have been relatively loose with their thinking and descriptions—one, in China, says it works “in partnership” with the public security bureau. Another, in Cambodia, announced that it looked forward to working with one of the centers to make it a “model of excellence.” This was a place that tasered and starved detainees. After criticism, the plan was shelved, but there is still no clear policy about when or how to engage. HIV experts have not gotten bogged down by the forced labor or human rights issues. They see their job as getting HIV services to people in need, and meeting their targets. In Vietnam and China, where the HIV epidemics are driven by injecting drug use, these centers are where the HIV is.

At our meeting, representatives from international humanitarian organizations talked about how they grapple with work in prisons, where people are also often treated badly, by making sure that they have unlimited access to all patients/prisoners, reporting abuses to authorities, and being ready to leave if they don’t feel like they’re making substantive change. It was clear that there are more questions than answers when it comes to current work in Cambodia, China, and Vietnam. It was also clear that most agencies working in these centers or on laws related to them, had not been given guidance on how to deal with the hard questions.  One HIV program implementer said there were no reported abuses in the centers they worked in—but then acknowledged that they had never asked.

The meeting was a great start, and we hope the U.S. Global AIDS Coordinator will issue formal guidance on the centers and call for their closure. Since the U.S. government is a many-splendored thing, even understanding who needs to be at the table to develop a guidance note is complicated: the drug control branch of the state department, known colloquially as “drugs and thugs” and more formally as the Bureau of International Narcotics and Law Enforcement Affairs, funds training in these centers.  The question of forced labor may be of interest as the U.S. engages in trade negotiations with Vietnam. We also met with Congressional and National Security Council staff, who we hope will investigate the question of how much the U.S. government is spending on work in or around these kind of centers and how abuses could be curtailed.

For closed and semi-closed societies, these kinds of ethical measures of benefit vs. harm are not restricted to detention centers.  Urging NGOs to engage with marginalized populations in facilities or countries where the moral dilemmas are stark means that all of us—donors, health implementers, and advocates—need to keep asking ourselves the hard ethical  questions as  we navigate the “rotten compromise.”

Advocates who work to improve the health of marginalized and criminalized people like drug users and sex workers must navigate a series of schizophrenic policies. On the one hand, international health agencies and public health experts affirm that these populations are at greatest risk for HIV and are in need of targeted, evidence-based health care services. On the other, law enforcement officials and their allies see the same people primarily in terms of their participation in illegal patterns of exchange. In this paradigm, for example, drug users—viewed as morally and legally suspect rather than as in need of services—are usually treated like illicit drugs themselves, as something to be isolated, controlled, and contained. While some term this a “balanced” approach, the reality in most countries is that law enforcement gets more resources and political support.

The human costs of this approach were highlighted in two Human Rights Watch reports released on drug detention centers in China and Cambodia. In these countries, as in Malaysia, Laos, Thailand, and Vietnam, detention centers are misleadingly labeled as “rehabilitation” centers—places of treatment. Yet they are run by military and police rather than medical professionals; include little or no health assessment of detainees; and often offer no treatment save military-style drills, forced labor, and chants such as “drugs are bad, I am bad.”

In Skin on the Cable, the Human Rights Watch report on Cambodia, one drug user recounts his experience:

On one occasion, I got shocked by a [electric] baton. It made me faint for a minute. It was the staff [who shocked me]. They said ‘You know you aren’t allowed to smoke.’ It’s like a burning sensation, real pain, you are shaking. It made me fall down to the ground.... I’ve been shocked three or four times. You get it for smoking, arguing, fighting. They have a couple of batons they leave on a wall charging.

Unlike prisoners, most drug users interned in these facilities have no right of appeal, never appear before a judge, and have received little attention from human rights monitors. Frequently, they also have no access to HIV or TB medicines, or in some cases, even to adequate food.

Virtually 100 percent of those interned in detention camps using this approach return to drug use when they get out, though in some places detention lasts for as long as five years.

The Open Society Institute’s Public Health Program and many of our grantees are engaging governments and international agencies to stop all forms of torture and ill treatment in health care, especially these most egregious cases of abuse masquerading as “public health.” Drug users demonstrating at a recent harm reduction meeting in Bangkok put it simply:  chaining, flogging, and forced labor are not treatment.

One can only hope authorities in Southeast Asia, and the UN experts advising them, achieve the same clarity soon.