By
Zsombor Peter and
Phorn Bopha
The Cambodia Daily
October 30, 2012
Ly Chan Long could not
recall just when it was that he first tried to quit heroin on his own.
He had been using for three or four years, and his first attempt soon
failed. Dates were still hazy. But he had no trouble remembering what
it felt like.
“It was like 100 diseases were inside my body and like my bones were
choking,” said the wiry 26-year-old with a thick, messy mop of hair and
the scraggly first wisps of a beard.
Since joining a government-run methadone program for heroin addicts
a few months ago he has managed to cut back to injecting once or twice
a week, with almost none of the withdrawal symptoms. The program hopes
to get Mr. Long off heroin altogether in a matter of months.
It is what the program has come to do well since Cambodia’s
first—and, thus far, only—methadone clinic opened its doors at Phnom
Penh’s Khmer-Soviet Friendship Hospital in July 2010.
Getting heroin addicts onto a daily dose of methadone and gradually
off of heroin has been the clinic’s success. But in almost every other
respects, the program is still struggling.
Both the clinic’s director and the NGOs he works with complain of
stubbornly low enrollment, poor drug counseling and not enough help
finding patients work and reconnecting them with family—the things
health experts say ultimately decide whether a methadone program
succeeds. Some of the NGOs also feel the clinic has given too little
thought to eventually getting patients off methadone, essentially just
a synthetic version of heroin with a longer, milder high.
“Where the problems are is everything behind the clinical process,”
said David Harding, international training coordinator for the NGO
Friends International, which works with drug users in Cambodia.
“The social aspects are lagging a long, long way behind still,” he said.
One of the clinic’s aims was to show the government a kinder,
voluntary approach to treating drug addicts that works. But the state
appears to have lost little enthusiasm for the centers where it locks
up some 2,000 drug users against their will each year and runs them
through military-style drills for a few months in the place of genuine
treatment. According to the World Health Organization (WHO), just about
everyone who goes through the centers soon relapses.
Plans to impose new user fees on the patients, or the NGOs that
sponsor them, could also threaten the collapse of the clinical side of
the program that actually works.
Slow Start
Mr. Chan Long, one of the methadone clinic’s
newest patients, started out taking yama—methamphetamine tablets that
take their name from the Hindu god of death—in 2003 with his friends.
Another group of friends put him onto heroin a few years later. To pay
for his habit, he painted motorcycles.
“But it was not enough money, so I would go out and steal. It could
be a motorbike, anything,” he recalled. A two-year stint in Prey Sar
prison, for beating a man while trying to steal his motorbike, did
nothing to stop his cravings. A few months at two of the government’s
drug centers also did nothing to help. After each stay, he went
straight back to injecting. Each attempt to quit on his own quickly
failed.
His home life suffered. “My parents sometimes chained me to a pole
in the house or locked me in a room,” he said. None of it worked, and
his parents eventually threw him out.
Living on the street, he would sometimes pick up clean needles from
outreach workers for the Khmer HIV/AIDS NGO Alliance (Khana), one of
two NGOs along with Mith Samlanh with a state license to run needle
exchange programs, which hand out new needles in return for used ones.
But even the clean needles Mr. Chan Long would share with two other
friends. He was soon diagnosed with HIV.
Down and out and sleeping rough, he finally let Khana sign him up for the methadone program a few months ago.
“It calms me down,” he said of the small cup of ruby red syrup he
now drinks religiously every morning at the clinic, a small,
refurbished stand-alone tucked away in a corner of the imposing
Khmer-Soviet Friendship Hospital.
“I still use heroin sometimes,” he confessed, as a drowsy expression
settled on his face somewhere between apathy and suspicion. “Less than
before, though, so I can save some money,” he added. Since starting on
methadone, he has also reconciled with his parents and moved back home.
But finding drug addicts to join the program is getting harder.
After enrolling about 100 patients in its first year, the clinic had
just over 130 at the end of its second, in July. That comes to barely
half of clinic director Chhit Sophal’s goal of 250.
“Our partners should work more…to refer [addicts] to the clinic,” he said.
Khana and three other organizations that work with the city’s drug
users mostly blamed stepped-up police sweeps over the past two years
for driving addicts deeper underground. The sweeps are part of the
government’s so-called “commune and village safety plan.” In
neighborhoods where outreach workers used to find dozens of users they
say they’re now lucky to find two or three.
“Since 2010, the government has put the safety plan in place and
the police try to clean up the drug user,” taking them off the street
and forcing them into the government’s drug centers, said Pin Sokhom,
outreach team leader at Mith Samlanh. “So they hide, and it gets
harder for the Mith Samlanh staff to find them.”
No one is sure just how many drug users there are in Phnom Penh, let
alone those injecting heroin.
Government and U.N. figures on drug
users nationwide vary wildly from a few hundred to 48,000. In an
evaluation of the methadone program after its first year for AusAid,
the Australian government’s international aid arm and one of the
program’s key donors, University of Adelaide professor Robert Ali said
best estimates from his sources suggested that Phnom Penh had some
1,500 injecting drug users, the vast majority of them most likely on
heroin.
The last time the government surveyed intravenous drug users, in
2007, it found one in every four of them were infected with HIV or
AIDS, the highest rate of any group in the country. By convincing
injecting heroin users to switch to methadone, the clinic was designed
to bring that number down.
But Prof. Ali’s report said the program would need to reach at least
40 percent of all injecting drug users, or up to 600 people, if it
hopes to make a difference.
The 131 patients enrolled at the methadone clinic as of September 30
comes nowhere near that. And with police driving potential patients
deeper underground, the clinic may not get near the number any time
soon.
Another Addiction
Besides bringing them patients, the methadone program relies on the
NGOs it works with to offer the social services it cannot, things like
vocational training and housing assistance and reconnecting patients
with estranged relatives. This way, each patient in the program
essentially gets sponsored by one of those NGOs.
Mr. Harding, of Friends, said his organization sponsors 15 patients
at the clinic but has grave concerns that the program has given little
thought to eventually weaning patients off methadone. After more than
two years, clinic staff say the program has yet to see a single patient
successfully give up methadone.
By working like a milder, longer lasting version of heroin,
methadone is supposed to give patients a chance at getting on with
their lives—find work, make a home and reconnect with family. But
methadone is still a drug, and still addictive. While patients
typically progress to smaller doses, it can take them years to quit
altogether. Some never do.
But in Cambodia, Mr. Harding said, “there is not a single facility,
institution or program that helps them detox from methadone, which
actually is harder to detox from than heroin.”
He said NGOs lack their own facilities to run a safe detox program
and are not licensed to administer the other medical drugs, like
codeine, often used to help the process along. The methadone clinic
has no such facilities, either.
“So you’re talking about a program that lends itself to continual expansion,” Mr. Harding said.
Bun Ratana, another patient at the clinic, is a case in point.
Now 28, he left home at 13 to escape an abusive stepfather and
ended up working on a deep-sea trawler in Thailand’s notoriously
abusive fishing industry, where crewmen are often fed amphetamines to
help them work through grueling hours in slave-like conditions. Mr.
Ratana started taking yama.
Returning to Phnom Penh in 2005, he joined the city’s tribe of
scavengers and soon added heroin to his diet, eventually injecting up
to five times a day. As he leaned forward to tell his story, his
shirtsleeves drew back and the pale green flames of a fire tattoo ran
up the inside of his left forearm like the teeth of an old saw. A
souvenir from the year he spent in Prey Sar prison for buying drugs,
he said. As with Mr. Chan Long, though, jail did nothing to stop his
cravings and upon release Mr. Ratana picked up his heroin habit just
where he’d left it.
He tried adding the occasional odd job to his scavenging, he
recalled, “but I could not work all day because the pain would hit me.”
Drug outreach workers for the NGO Korsang finally steered him to the
methadone clinic and Mr. Ratana became one of its first patients in
mid-2010. He has stopped using heroin, now has a wife and a 1-year-old
son and works as a parking attendant.
“I don’t have to spend all that money on drugs and I can save for my
kid,” he said with a ready smile on a recent morning at the clinic.
“It’s a really good program; it’s helped me a lot. It’s like I’m
reborn.”
But asked if clinic staff had ever broached the idea of trying to
take him off methadone at some point, he knitted his brow as though the
thought had never even occurred to him and shook his head.
It is what the NGOs are worried about. Beyond handing out daily
doses of methadone, clinic staff are falling short with almost
everything else. More than two years on, they say some patients are
still not getting their regular monthly addiction counseling and that
the counseling they do get is of poor quality.
And though the clinic keeps no running tally, NGOs say more than
half the methadone patients—even those who have quit heroin—keep using
or pick up other drugs.
“What we really need for our clients is the psycho-social part; they
need [better] counseling,” said Taing Phoeuk, Korsang’s executive
director. “We try to counsel them the way we know how,” he added, but
confessed that his own staff has no professional training.
Asked about the criticism of the program, Dr. Sophal smiled knowingly and sighed.
“This is our challenge…because our team don’t have much experience for that. The skill is not good enough,” he said.
Paying the Price
Dr. Sophal lays much of the blame on the on-again, off-again supply of salary supplements to his staff for fostering low morale.
Part of a nationwide program to improve the public sector, several
of Cambodia’s foreign donors had for years been paying salary
supplements for state employees working on donor-funded projects like
the methadone clinic. By substantially boosting their modest public
salaries, the supplements were supposed to encourage civil servants
to work full days instead of checking out early for better-paid second
and third jobs in the private sector. But behind-the-scenes wrangling
between donors and the government over who should get how much
periodically derailed delivery.
Officials at the Finance Ministry have declined to comment on the
salary supplements. But several donors confirmed that they pulled out
of the program again in July after failing to agree with the government
on how to keep the program going.
To keep the supplements to its staff coming, the methadone clinic
came up with an “equity fund” to be filled by charging the
patients-—or, more likely, the NGOs sponsoring them—for service. A cup
of methadone each morning, for example, would cost $2. A session with a
drug counselor would cost $2.50.
Dr. Sophal reasons that methadone clinics in other countries already
charge such fees and figures that patients could put some of the money
they spent buying drugs toward helping themselves get well at the
clinic. The most indigent would still be exempt from the fees, he added.
“If the patient decides to come,” even if they have to pay, he said, “they commit to coming; it means they are committed.”
Several donors have agreed to help cover the clinic’s fees for now.
But once the NGOs hit their new fiscal year next summer, Dr. Sophal
said, the burden could still shift to them.
That has both the NGOs and the WHO worried.
What works elsewhere may not work here, said Yel Daravuth, the WHO’s
resident substance abuse specialist. “In the West they can afford it,
but if you look to this country they do not have the money and they
have to [spend it all] just for their food. So it’s going to be quite a
challenge in this country,” he said, even for the NGOs.
The NGOs see a calamity coming. Korsang’s Mr. Phoeuk is especially
worried. With some 90 methadone patients under its wing, his NGO
sponsors the most of any. If those patients can’t pay, and Korsang
can’t pay for them, there is little they will be able to done.
“For Korsang it won’t work,” he said of the user fees. “Just for dosing, take $2 times 90. We can’t afford that.”
Korsang would have to spend $65,700 a year for methadone alone, not
including the follow-ups and counseling the patients need just as much.
There would even be a $2 fee for a first-time consultation with every
new patient the NGOs bring in.
“It’s not really been thought through,” Mr. Harding said.
If the fees do end up falling on the shoulders of the patients or
the NGOs sponsoring them, he warned, “You could see a 50 percent
dropout [of patients] almost immediately, and that’s not going to look
good for anybody.”
Should that happen, the clinic would be even further from reaching
the 600 patients it needs to start bringing down HIV and AIDS infection
rates among intravenous drug users, the clinic’s very raison d’etre.
And it would make it only harder to convince the government to close
down its notorious drug centers, another of the WHO’s goals.
The government calls them rehabilitation centers, though the U.N.
and NGOs say they fail to do any genuine rehabilitating. The centers,
10 in all, were in the spotlight in 2010 when the U.S.-based Human
Rights Watch (HRW) released a scathing report that drew on dozens of
interviews with former detainees. It accused the facilities of not only
failing to treat drug users but often subjecting them to physical and
sexual abuse.
Government officials have repeatedly denied the harshest claims,
but in July, HRW again called on Cambodia to close the centers down.
The National Authority for Combating Drugs (NACD) rejected the idea.
“Of course, it [the government] cannot shut down the drug
rehabilitation centers,” Meas Vyrith, the NACD’s deputy
secretary-general, said at the time. “Why do they just always
recommend closure? Do they want the drug users walking around?…. I
think Human Rights Watch should build a drug center by itself to
satisfy its demands.”
The methadone clinic and another voluntary program for treating
drug users, now taking shape in Oddar Meanchey province’s public
health clinics, are signs that attitudes toward drug addiction
treatment may slowly be starting to change. But the government’s drug
centers are still open. Just last month, the Social Affairs Ministry
reminded Vietnam of a long-standing offer to fund the construction of
what would be Cambodia’s largest government-run drug center in Preah
Sihanouk province.
As Mr. Harding at Friends sees it, the government has come to a
fork in the road‑—forced treatment down one path and voluntary
treatment down the other—and decided it had no reason to choose just
one.
“There’s still the same number of centers; they’re still working the
same way,” he said. “They’re basically saying ‘We’ll take both, thank
you very much.’”
Dr. Sophal, who also wants to see the government abandon its drug
centers, is willing to wait and let the methadone clinic speak for
itself.
“It’s long term, not just one or two years,” he said.
He offered an analogy that Adam Smith, the godfather of the free market, would surely have appreciated.
“The [clinic] is a restaurant and the government [centers] are a
restaurant. What kind of food do they serve? What kind of noodle? If
the food is more delicious, they will come.”
Vietnam overtook China to become the largest producer of Nike shoes in 2010.
