Understanding of the Rationale for Decriminalisation Policy
Since 1999, alongside sex workers, drug users were identified as ‘social evils’ and linked directly to the HIV epidemic in Vietnam and often sent to mandatory rehabilitation of up to two years in a CTC. As the numbers of people detained in CTCs rose exponentially, several participants commented that the workloads of police and staff at the CTCs became unmanageable [6]. Significant international criticism of the negative impacts to human rights in the CTCs created an internal country debate [7, 8], as a representative of MOLISA commentated,
You need to remember that after the second CCV passed in 1999 with a focus on the criminalizing of drug use in article 199, it led to repressive enforcement approaches for those with drug addictions. Vietnam then endured a significant overcrowding of the prisons with people who used drugs across the whole country. That was matched with more enforcement to populate the CTCs with drug users and then manage the workload and the growing activist dissatisfaction with the CTCs. The health care of drug users suffered, and the rate of drug users did not decline nor did the rate of HIV/AIDS among people who injected drugs. It was obvious that criminalizing drug use was not the excellent solution that it was meant to be (Interviewee #10).
Vietnam’s 1999 CCV aimed to strictly regulate drug users as offenders, rather than people with health problems highlighted by several participants who noted;
We thought that the harder punishment would lead to easier control of drug user numbers and decrease drug trafficking however this was a miscalculation on our behalf (Interviewee #6).
At that time, we considered that reducing demand via putting drug users in jail would be effective measures in reducing supply…however, that was wrong (Interviewee #5).
From 1999 to 2009, between incarcerating people who used drugs as a criminal offense or alternatively sending people to CTCs under an administrative violation, Vietnam did not demonstrate any decrease in drug demand [3] with an increase in the number of drug users registered with authorities from 55,455 in 1994 to 178,305 by the end of 2007 and the number of CTCs increased from 56 in 2000 to 123 by end of 2010 [6, 9]. Between 2000 and 2010, approximately 309,000 people had been detained and treated at the CTCs [6, 9]. Yet there was a growing realization from a range of anti-narcotics’ authorities from central level down to the ward police that the relapse back to drug use from people leaving the CTCs was estimated at 80-90% and in some provinces reached 95-100%, [10]. Furthermore, HIV prevalence amongst people who injected drugs continued to increase which had serious implications for the health system of Vietnam. A key informant who was also a medical doctor before joining MOLISA, recalled;
Putting them [users] in the jail or CTCs without necessary interventions and effective solutions in terms of health and treatment just increased the risk of infectious disease to this population of people (Interviewee # 10).
The lack of success of the drug user criminalization approach became obvious to both the Party-State and the broader community [7, 8]. This situation forced officials to begin to re-consider how to re-structure drug policy in Vietnam. At the same time the international literature investigating the effect of decriminalization policy on rates of drug use from predominantly western settings either indicated no remarkable rise in drug use after decriminalizing [11, 12], a marginal increase [13, 14] or difficulties reporting any trend on drug use [15, 16]. The evaluation of the Portugal model however highlighted that decriminalisation of drug use had resulted in decreased crime, decreased incidence of HIV and increases in the number of people voluntarily seeking drug treatment [17]. This model was reviewed by Vietnamese policymakers and enabled learnings and momentum towards a decriminalisation policy in Vietnam [3].
Overcoming Political Attitudes, Ideologies and Expanding Harm Reduction
Despite many Party officials being in favour of closing the CTCs and voting for decriminalisation due to an entrenched culture of police-led arrest of drug users and the economic interests in the local government management of CTCs, there was resistance to the decriminalisation policy amendment [8]. Therefore, when the National Committee of Social Affairs called for decriminalization drug use and the NA voted in June 2009 there was not unanimous support for the policy;
At least 35,7% (176 participants) disagreed and 2,23% (11 participants) did not vote among the 449 attending participants. This left only 53,14% (262 participants) agreeing to decriminalize drug use reflecting conservative hesitations although it did pass (Interviewee #1).
When Vietnam decriminalized drug use in their criminal law system, many worried about the effectiveness of this change because harm reduction itself had not yet become ingrained in Vietnam and the CTCs system was not being dismantled [8, 18, 19]. Although Vietnam was concerned about the HIV prevalence among PWUDs the adoption of harm reduction was very slow, and it wasn’t until the National Strategy for HIV Prevention and Control and its Law passed in 2004 and 2006 respectively that harm reduction was fully endorsed which health officials knew was too slow in happening.
As doctors and nurses, we worried and concerned that this process had been too slow (Interviewees #1,10,13).
In early 2009, a methadone maintenance treatment (MMT) program was piloted at six community-based treatment facilities in Hai Phong and Ho Chi Minh City providing MMT to 1,685 patients [20]. Of these patients, 979 were enrolled in a two-year evaluation study between January 2009 to September 2011 in a project supported by USAID, PEPFAR [21] which showed that ‘MMT significantly reduced illicit heroin use in participants and, among those who did continue using heroin, greatly decreased frequency of injection.’ MMT was rapidly scaled up and by 30 June 2012, the national MMT program had treated nearly 10,000 patients in 12 cities and provinces [22]. The MMT program outcomes have improved health outcomes and proved more cost effective than CTCs and have been shown to decrease crime [7] as well as build further nationally relevant evidence of the benefits of patient-centered treatment as part of a harm reduction framework [23].
Police Engagement at the Interface of Drug Control and Harm Reduction
Within a fairly short period of time, decriminalisation, community based MMT and an active needle and syringe distribution program (NSDP) were all coexisting within an environment that still prioritised strict drug control where drug users continued to be regularly under threat of arrest by police. The NSDP, managed by the Ministry of Public Health, contributed to reducing the rate of needle and syringe sharing among injecting drug users and a reduction in HIV prevalence among injecting drug users from 29.35% in 2002 - 2003 to 19, 66% in 2009 [20]. Yet almost all police officers at that time thought the NSDP was leading the users to relapse [1, 24] and police continued to be taught in their police training that using illicit drugs, even once would inevitably leads to prolonged addiction [25].
These divergent perspectives between the health sector and law enforcement contributed to the ongoing police support for abstinence-based approaches such as CTCs. Specific work examining the role of police in harm reduction programs in Vietnam [24, 26, 27] highlighted that police would prioritize arresting and detaining drug users rather that support their access to harm reduction which is a situation that still prevails today. It took almost five years after the implementation of the decriminalisation policy for the first national consultation workshop to discuss the development of police training materials on harm reduction interventions and the prevention of HIV, which largely focused on the occupational health and safety of police.
That’s why during this gap time [2009-2013], we did not know exactly what role and responsibilities were in dealing with drug users to support their access to the standard harm reduction interventions. All we were really taught was how to protect ourselves to avoid HIV exposer from users and in case of exposure, how to promptly handle to minimize HIV risk (Interviewee #2).
Police officers in this study further affirmed that;
‘…drug use and addiction are the fastest pathways to criminal behaviors….and that drug use makes up the highest number of offenders across society’ (Interviewee #7)
‘…preventing and combating all drug-related crimes are our most prioritized duties. Nothing more, nothing less’ (Interviewee #4).
There has been virtually no training given to police about harm reduction or the implementation of the decriminalization policy [24, 26].
Despite the decriminalisation policy, the perceived ineffectiveness of community-based treatment and a persistent political commitment to anti-drug rhetoric such as “Drug free ASEAN” continues to see the Government of Vietnam implement strict management and tough control over drug users via CTCs which expanded in number to 123 centres between 2012-2015 after an initial scaling down [25, 28]. Human resources and technical capacities still limit the effectiveness of community-based treatment and relapse remains common which undermines the police and community support for health-based drug policies and perpetuates drug-related stigma [19]. The police team in Nghean commented on the issue of under resourced community-based treatment programs;
If resources are not enhanced, it will be impossible and they [local authorities] must take over and deal with the task, including our policing duties [collecting and sending users to courts], and therefore, up to now, most of the post-detainees who have returned to their places of residence have not been supported to stabilize their lives, which is one of the reasons for their early relapse (Interviewee #2)
Indeed, among local authorities, ward police officers are considered the frontline force to manage post-detoxification users when they re-integrate into community as well as support and guide them to stabilize their life [18, 25, 26]. Yet police do not always see the role as holistically as it is described above;
Our duties are still to monitor and call them anytime if we suspect they have relapsed and are involved in other criminal activities. Supporting them to stabilise their life is not our duty because we have to carry out a number of different inquires (Interviewee #5)
From the establishment of the professional anti-narcotics police force in 1997 through to the decriminalisation of drug use in 2009, there have been irregular meetings and symposiums between MOH, MOLISA and MPS focused on supporting the police to avoid occupational HIV risk in their work combating drug-related crimes [28, 29]. Occupational HIV risk reduction is an important part of police safety but it is unlikely to improve their engagement, attitude or willingness to support health-orientated drug policy. When asked what a national harm reduction training for police should include, a retired senior police officer suggested,
The ideal training framework is on how police can support service provision for PWUDs. It should be designed in order for police to implement at scale across an entire policing service and thereby significantly enhance the ability of police forces to contribute to the national drug policy’s response. The program should be implemented across policing education at all levels; from basic recruit training through to ward police and indeed with senior leadership positions in anti-narcotics police forces (Interviewee #6)
Efforts to better integrate policing and decriminalisation
In February 2019, the Hanoi People's Committee issued Plan No.40/KH-UBND titled “Social and Legal Consulting, Assisted Referral Model for People who Use Drugs”[1]. A pilot initiative to support long-term drug dependence treatment through referrals to health, legal and social support services to help people on treatment integrate into the community, prevent relapse and achieve the highest physical and mental health. It was also designed to ensure police had a definitive option to contribute to health-orientated approaches to drug use. Based on a model of police assisted diversion (PAD) where police assist PWUDs connect with the health, social and legal services rather than arresting people or sending them to CTC. It is a partnership project involving police, government and civil society organisations. One of the project partners from civil society noted,
This is the first model in Vietnam to trial the participation of police in introducing, connecting and supporting drug user access to voluntary counselling and support agencies in their community. An initiative implemented in two districts with six communes in Hanoi and it will hopefully help contribute to concretize harm reduction in policing (Interviewee #1).
Observers of the pilot including a senior officer of MOLISA and a retired police officer commented;
We call it [this model] voluntary treatment in the community supported by relevant medical, social and legal services (Interviewee #10)
This pilot will demonstrate the abilities, duties, and responses of police officers to cooperate and collaborate with multiple civil society and social affairs in harm reduction approach, if their high-ranking level in the MPS support it then it will be extended other locations in the future (Interviewee #6)
Based on Seattle’s Law Enforcement Assisted Diversion (LEAD) program [30], the goal of the model is to create conditions for early stage drug users to participate in drug treatment as well as prevention and treatment of HIV, Tuberculosis and Hepatitis B/C in their respective localities. The project aims to reduce the number of people referred to compulsory detoxification, reduce engagement in crime and improve the quality of life of people who use drugs. Planning No.40 stipulates that local ward police must provide drug users with assistance to access support, counselling, drug dependence treatment and referral to health, social and legal services [30]. This model will hopefully illustrate that decriminalisation and a health orientated approach to drug use is more effective than sending PWUDs into CTCs for up to two years. One participant noted,
Clearly, when the courts sentenced people to death it pushed the penalty frame for drug crimes to the highest punishment, but drug-related crimes did not decrease at all. So, when making policies, we must not think that increasing penalties is an effective solution. How is the punishment commensurate with the behaviour? Drug use and drug trafficking are totally different activities (Interviewer #6)
[1] Hanoi is the first city in the country to pilot the model, which is co-managed by the MOLISA and the Hanoi Department of Social Evils Prevention, with the technical support from the Centre for Supporting Community Development Initiatives and financial support by SAMHSA. In the first stage, the model has been implemented in two districts - Long Bien and Nam Tu Liem with 6 communes (Ngoc Lam, Ngoc Thuy, Bo De, Cau Dien, My Dinh 1 and Xuan Phuong). It officially operates throughout 2019-2020 and is expected to work with 150 people. The financial supports for the year of 2019 is around VND1 million (USD 450,000).