The ethics of drug addiction research in China

Reports about what goes on in 'drug rehabilitation centers' in China have been dribbling into the media for some time now. Arrest for illegal drug use in China can lead to compulsory treatment (for a minimum of 2 years) at detention centers that, according to a New York Times piece in 2010, function as de facto penal colonies where inmates are fed substandard food and denied basic medical care. The detentions are enforced by police, where the drug user has no opportunity to have a trial, face a judge or raise an appeal. When a drug user leaves detention, the problems do not end there: their having been arrested for drug use is noted on their national identification card, making future employment difficult and leaving them vulnerable to frequent and humiliating searches by police. This is not a rare phenomenon: according to the Joint United Nations Programme on HIV/AIDS (UNAIDS, 2010), half a million people are confined in drug detention centers in China at any given time. Perhaps it would be marginally better if those with drug addictions received effective treatment during thier detention, but the most reports point in the other direction: 'treatment' may come in the form of unpaid labor in chicken farms or shoe factories, or in the form of untested 'therapies' like sandbox play, art, or boxing. The 'treatment' looks like punishment, exploitation, or merely lame.  


Question: would it be ethical to conduct research with drug user detainees in such circumstances? In the abstract, those with substance abuse problems are vulnerable persons in poor health, and it would be good to have research on effective interventions to combat drug addiction. But in practice, it gets complicated. The journal Science recently published an article entitled 'A memory retrieval-extinction system to prevent drug craving and relapse'. The study was conducted at Beijing Ankang and Tiantanghe Drug Rehabilitation Centers, but these are two of the facilities that have raised concerns about human rights violations over the past years. Human Rights Watch has published a Letter to the Editor in Science that raises concerns about research being done within institutions suspected of human rights abuse. Should a new intervention be tested against the local standard of care, where there are serious doubts about the effectiveness of that care? In these circumstances, is voluntary informed consent of participants really possible? Are researchers who conduct research in these facilities complicit in the ill-treatment of drug users at the hands of Chinese authorities? 


The story is made murkier by the involvement of the US National Institute for Drug Abuse (NIDA) in the study. Two of the authors on the study are from the NIDA, who apparently helped with data analysis and the writing of the article. Since they were significant enough contributors to the research to warrant authorship, should the study have also been reviewed under the (rather stringent) US regulations governing prisoner research, and if it did, would it have passed muster? It will be interesting to see how this case evolves as the facts become clearer. 

A novel approach to fighting HIV infection among drug addicts: acceptance

The New York Times has an interesting article this week on HIV and drug addiction. As has been known since early in the epidemic, intravenous drug use is a pretty efficient way of transmitting HIV. Addiction also leads to behaviors -- like trading sex for money and drugs -- that further multiplies risk. For those working in public health, intravenous drug users are a challenge; they are often called a 'hard to reach community' for good reason, because what they do is illegal, and they have to duck and cover for fear of being turned into the authorities. The group is also deeply stigmatized by the wider community: as trash, car crashes, disease-vectors, worst case scenarios. Those in bioethics who talk about protection of the vulnerable are usually not thinking about drug users: the preferred vulnerable are typically the non-addicted poor, the non-addled disabled, or innocent children and fetuses. (Bioethicists steer clear of that part of town, mentally as well as physically.) There is always the spoken or unspoken accusation of addicts being responsible for their predicament, and there is no way around it: a lot of drug addicts are in rough shape and live in rough circumstances. Some of the photos accompanying the New York Times piece are cringe-evoking, and leave no room for romanticizing drug use.

That should not take away from the point of the article, however. St. Paul's Hospital in Vancouver has set up Insite, a place downtown where injection drug users can get clean needles, and get tested and treated for HIV. A package of medical services is offered by staff nurses: basic care for needle infections, gynecological exams and tests for sexually transmitted diseases, and referrals for drug treatment. The strategy of aggressively testing for and treating HIV seems to be working: HIV incidence in Vancouver has apparently fallen by half. Up to now, Insite has managed to get an exemption from Canada's narcotic laws, so drug users can shoot up inside the premises without the risk of being arrested or robbed, and stand less chance of dying of an overdose.

The program is unusual in its acceptance of the grim reality of addiction. Most often, public health approaches with this community are strongly mediated (or hampered) by common sense morality, the law, and politics. For example, a number of studies worldwide have shown that clean needle exchange programs can play an important role in lowering HIV transmission, but such programs run headlong into stigmatizing attitudes about addicts and have only rarely been fully embraced. The Insite initiative gives a glimpse of what public health interventions with this population could be like when they are provided with funding, legal immunity, and minimal political pushback and moralizing. It looks like such programs could do some good on individual and population levels. While this approach might catch on, at least in Canada, other affluent countries (like the United States) are far away from having the social and political conditions to emulate this model, and others in developing countries are even further still.

Forced trials of drug users in Cambodia?

This is one of these stories in ethical flux. Human Rights Watch (HRW) has claimed that earlier this month the Cambodian police rounded up at least 17 drug users and brought them to a government-run drug detention center on the outskirts of Phnom Penh, where they were forced to participate in a drug study. The drug being tested is 'Bong Sen', a herbal substance that is alleged (by the company that makes it) to detoxify heroin/opiate users in 4-5 days. HRW lays out the ethical problems with the experiment: coercive recruitment and lack of informed consent; lack of review of the study by the ethical committee of the Ministry of Health; unknown (and possibly shoddy) study methodology, including apparent lack of follow-up of research participants.

The British Medical Journal put out a small piece on this story last week, providing some interesting details. Bong Sen is produced by a private Vietmanese company, with a very strange looking (and long) name: Ben Tre Fataco General Import-Export Trading Service Company (kor Ben Tre Fataco, for short). According to NGOs in Cambodia, Ben Tre Fataco has formed a group with four Vietmanese doctors, a company in Cambodia marketing Bong Sen, staff from Cambodia's National Authority for Combatting Drugs (NACD) and its Secretariat-General, the Ministry of Health and the Orkas Knhom drug treatment center, which is run by the Phnom Pehn municipality's Department of Social Affairs.

Just to show how deep the government is involved in the Bong Sen trial, the Cambodian prime minister is said to have given the Vietnamese doctors written permission to administer Bong Sen to drug users. When the Orkas Knhom drug treatment center could not come up with sufficient 'volunteers', staff from the NACD are said to have demanded that clients at local NGOs take the medicine. The NGOs hesitated, given that the herbal medicine being pushed did not seem to go through routine drug trial procedures. Staff from the NACD then threatened the NGOs with closures and withholding their licences for needle-exchange programs. That is apparently what went on before the police arrested drug users and had them enter the Bong Sen study. For its part, the NACD has denied everything: the drug users were volunteers; the herbal treatment is not really a drug, and does not have to go through drug approval procedures; there is no real trial at all. Just giving out medicine.

One thing is certain: the relationship between the Cambodian government and Cambodian citizens who happen to be drug users is not very warm and friendly. Earlier this year, the Soros Institute put out a report entitled At What Cost? HIV and Human Rights Consequences of the Global 'War on Drugs'. One chapter of the Soros report is dedicated to the arbitrary detention and police abuse of drug users in Cambodia. But this is nothing new. There have been reports about government abuse of Cambodian drug users (many of whom are HIV-positive) for at least a decade. If the allegations are true, the question is why the Cambodian government would be so interested in corralling drug users for this particular trial. Is it just because Bong Sen is a non-opiate treatment? What interests does the government have in the success of Bong Sen treatment that they are deeply involved promoting as effective despite there being no evidence of its efficacy? As the BMJ piece notes, no one is talking: Ben Tre Facaco is not answering its phone or email, and the Cambodian Ministry of Health has nothing to say.