Rehabs in need of rehabilitation
On February 6, 2016, 27-year-old Shariful Haque died of pneumonia after being given an ice bath treatment by the doctors of his drug rehabilitation centre in Pabna.
What is the ice bath treatment? Shariful was made to sit in an icebox filled with ice for up to five hours a day. The deceased was a computer science graduate from BUET. He was admitted to the rehab three months prior to his death.
For all latest news, follow The Daily Star's Google News channel. His family reports that his dead body also bore signs of torture—a cut lip, burn marks on his back.
Early last month, 37-year-old recovering addict Jalal Uddin's dead body was discovered in an ambulance in the parking lot of a drug rehabilitation centre in Moulvibazaar. The rehab was completely empty—everyone had fled the scene.
A photo of the dead body showed several long diagonal welts on his upper arm, where the patient was hit with blunt force. With each hit, blood congealed under the skin turning the whole area a deep shade of red-purple. A circular bleeding wound nestled in between the welts.
Jalal Uddin was a patient at Uddipon Rehabilitation Centre where he was undergoing treatment for addiction. Clearly, none of these torture methods are part of any prescribed treatment plan for treating drug addiction.
"There were injury marks all over the dead body," the victim's uncle Emdadul Haque told our Moulvibazaar correspondent. "We got a call on the evening of January 6 saying that our brother was very sick and was being taken to Sylhet's Osmani Medical College. We rushed to the hospital but could not find my nephew, so we went directly to the rehab."
They discovered that the entire premise was empty. There was just an ambulance parked on the lot, and to their dread, they found the dead body of Jalal inside.
In the past year, over 260 drug dealers were killed in incidents of "crossfire" with the law enforcement in a 'shoot first ask questions later' policy. Rights groups including Ain o Salish Kendra have pointed out that this was the highest number of extra-judicial killings in the country's history. To add to the bloodshed, the outgoing parliament passed the Narcotics Control Bill 2018 which introduced the death penalty for possessing as little as three tablespoons of heroin. In a scenario where the legislative and the executive branches of the government are clearly focusing on criminalising drug abusers and dealers, how much effort is being directed towards actually treating and rehabilitating addicts?
The Department of Narcotics Control said that the director of the rehabilitation centre where Jalal was killed was arrested, and their license was revoked. But the chapter cannot close there, because although this one centre was shut down, there are many others doing the same. In fact, Jalal's death highlights a whole list of things broken about the system of drug rehabilitation.
Jalal was admitted on December 29 to treat his heroin addiction—and he was discovered dead on January 6, exactly a week after. According to the timeline, during the time of his death, he was going through drug withdrawal—a process that turns heroin addicts violent.
"Opioids like heroin cause people to relax. Withdrawal from the drug causes the patient to become violent," says Tarun Gayen, the chief executive officer of CREA Drug Addiction Treatment Centre. Circumstantial evidence suggests this—Jalal was potentially going through severe, violent withdrawal and the rehab administration used excessive force to try and control him.
This possibly could have been prevented if Jalal had access to a drug called methadone.
"Methadone has the same effects on your body as opioids like heroin but it is a synthetic compound, instead of being naturally sourced from poppy flowers. This is given to recovering addicts, whose drug supply has been cut off, and whose bodies are in withdrawal," explains Dr Lutful Kabir, the resident psychiatrist of the government-run Central Treatment Centre in Tejgaon.
Basically, methadone fools the body into thinking it is still getting heroin or phensidyl, while the body naturally rids itself of the drugs.
Unfortunately, this treatment, known as the Opioid Substitution Therapy, is only available to a select group of people under a small project that has been going on for the past decade, and is yet to be introduced among the general public.
The government centre in Tejgaon is one of the only places in which this treatment is available. Recovering addicts—all of whom are outpatients, instead of being inmates of a rehabilitation centre—come to the clinic every day to take their dose of methadone. They walk up to the booth calmly, sign an attendance sheet, chug a pink liquid from a a plastic cup, and go off again to lead their lives.
They are all part of a project that began in 2010, but is yet to expand fully.
We started with the help of United Nations Office on Drugs and Crime in 2010 following massive advocacy with Department of Narcotics Control recognising the benefits of Opioid Substitution Therapy (OST)," says Ezazul Islam Chowdhury, Senior Programme Manager of the HIV and AIDS Programme at International Centre for Diarrhoeal Disease Research (icddr,b). In the advocacy process the Directorate General of Health Services, UNAIDS and others were involved.
"Currently there are seven clinics inside Dhaka that is giving the service to about 1,000 people who inject drugs. Two more are in the pipeline at Cumilla and Narayanganj. If those get built then the total number of people reached will be approximate 1,700," adds Chowdhury. Along with icddr,b, Save the Children, CARE Bangladesh are also implementing the OST.
"Only icddr,b has the license to procure methadone from international source as it is not produced locally. As this is a narcotics drug, safety is always an issue and therefore, Narcos is very cautious about giving import permit to others. Moreover, a trained and dedicated treatment team is required for handling this," says Chowdhury. Due to this strict guideline the drug is yet to be introduced in rehabilitation centres for widespread use, so as to keep a tight grip on its circulation. This is a very valid fear, agree experts. "Buprenorphine, another drug that could have been used for OST, cannot be used in Bangladesh because drug addicts routinely abuse it," states Dr Kabir.
The project also only targets people who use needles and syringes, because the overarching goal of the project is to reduce the transmission of HIV—drug dependance who took the drug by any other means have no other option than to go through cold turkey detoxification. But once again, because of the small number of beneficiaries, the programme is hardly making a dent.
"The prevalence of HIV among people injecting drugs is 20% in Dhaka city right now. In parts like Old Dhaka, the rate is over 27 percent. As per WHO set target, we need to reach at least 40 percent of our target group with OST if we want to see its in HIV prevalence" states Chowdhury. This urgency is further exacerbated by the fact that current OST programme run by Global Fund project will run out of funding by 2020.
"The government funded this project from 2012 till 2016. Since then we have been run by the Global Fund only, and our funding will dry up by 2020. The government currently has allocation for OST services for another 1500 individuals. This is very urgent to start the implementation of that considering the sharp increase of HIV," says Chowdhury. He also added that current government leadership are sincerely trying to bring OST under its wing. A report published by Harm Reduction International in December 2018 found that when it comes to programmes like OST, there is a 90 percent shortfall in funding for low to middle income countries like Bangladesh.
SM Zakir Hossain, the Director of Treatment and Rehabilitation of the Narcotics Department, however thinks that no one method is better than the other. "Any patient can relapse, and rehabilitation helps mitigate that by building new habits."
Aditya Kabir, a recovering drug addict, also agrees with him. He found that the natural detoxification method worked for him. "We are made to get into a structured lifestyle in rehabs. We take classes on how to identify emotions, how to look for triggers that can make us abuse drugs. We form deep bonds with our peers and maintain accountability with each other," he states, describing his overall experience through rehab as a positive one.
A public health issue?
Making available drugs that aid detoxification is, however, only one part of rehabilitating drug addicts. Harm International's report, titled "The Global State of Harm Reduction 2018" scores a country based on what facilities it provides to citizens abusing drugs.
According to the report, Bangladesh does not have any facility to distribute a life-saving drug called naloxone that can save the lives of people who are overdosing on drugs. India however does, and so does Afghanistan, the only other country in Asia. Both countries have programmes that distribute the medicine to friends and family members of drug addicts.
Bangladesh does have a robust programme aimed at delivering clean needles and syringes to drug addicts, and delivered 158 needles to every person who injected drugs, observes the report. This is half the World Health Organisation's recommended number of 300 per addict. On the other hand, a qualitative survey done by a team from University of Rajshahi in 2016 found that the number could have been higher if stigma did not come into the play.
"The addicts interviewed state feeling stigmatised by the field workers who give them the needles and syringes. They know what they are doing is harmful but they still need to be accepted," states M Kamal Pasa, assistant professor at the department of anthropology, who was one of the authors of the paper titled "Sharing of Needles and Syringes among Men Who Inject Drugs: HIV Risk in Northwest Bangladesh."
Out of control
There are 286 licensed rehabs all across the country, and 60 more seeking licenses—but the trouble is nobody knows how many are operating without licenses.
"I myself shut down six such drug rehabilitation centres in the last year," says Khurshid Alam, assistant director at Narcos.
"Natun Asha, a centre in Uttara for example kept their patients in extremely cramped conditions, and we did not find any doctor or nurse present on spot," he describes. "The same was seen in Hira and Mukti, two centres in Mirpur." The law states that for every 30 patients there has to be one doctor present at all times, one psychiatrist and two nurses.
"There was one place in Mohakhali where patients alleged being beaten up. We went to inspect, and they somehow got tipped off. They stuffed all the patients in a room on the highest floor. When we met them, they told us we could not speak to the patients because there were none present! We found them while inspecting the building," narrates Alam.
This correspondent herself tagged along with law enforcers on a similar inspection visit on November 26, 2016, and saw first-hand the conditions in which Mukti Rehabilitation Centre kept their patients.
The kitchen stored expired packets of packaged food, and the surroundings were unbelievably filthy. Clusters of cockroaches camped out in the clogged kitchen sink, hid out in the food and cutlery storage area and scurried away on the floor.
Patients complained that they were not told what drugs they were being prescribed. "I want to know what medications I am being given and I'd like to know what effect it's having on me. I believe it's illegal to give me medication without my knowledge," said a recovering inpatient.
"I am being given this pill at night and it constantly makes me dizzy and unsteady on my feet but I am never told what it is, nor are the side-effects ever discussed with me," he added.
"They force feed us pills to dry-swallow if we don't want to take the medication."
However, Mukti has straightened up since then, states Alam. "We visited them four times and found no complaints," he says.
Narcos officials believe that rehab centres often operate under such terrible conditions because of the stereotype that drug addicts are criminals who need to be jailed in prison-like situations.
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