Jimmy Brown

Ley Van Hope recovers in Calmette Hospital, thanks to Korsang.

For ten days Ley Van Hope could only watch as the excruciating abscess on his hip

swelled to the size of a tennis ball. As a long-term heroin addict, seeking medical

attention was not an automatic response.

"I didn't want to go and get help. I didn't think about treatment. I just wanted

to die," he said. "But my friends knew about an NGO and they persuaded

me to go there for medical treatment and help to stop using drugs."

But Hope's delay in seeking treatment allowed his injection-related abscess to worsen.

His femoral artery burst causing him to lose several pints of blood and he was rushed

to Calmette for surgery. Thanks to local NGO Korsang - which in Khmer means "to

rebuild" or "to fix" - and Professor Heng Taykry, the hospital's executive

director, Hope is recovering well. But many of Cambodia's drug abusers are not so

lucky.

According to an unpublished draft of Cambodia's National Treatment Policy (NTP),

prepared by the National Authority for Combating Drugs (NACD), drug use has accelerated

dramatically in Cambodia over the last ten years.

"Since the mid-1990s Cambodia has experienced a rapid increase in the population

at risk for use of illicit drugs such as methamphetamine, heroin, opium, ecstasy

and other synthetic drugs and cannabis," the NTP reads. "The number of

those estimated at risk of illicit drug use has risen from virtually zero in the

early 1990s to an estimated level at present of up to 600,000 people or 4-to-5 percent

of the population, with many belonging to the 12-to-15 age group."

From local health workers to the upper echelons of the government, the upsurge of

drug addiction and drug-related health problems has become a cause for concern. Officials

say the government is well aware of both the risks posed by increasing drug use and

of its own responsibility to help. In 2003, Hun Sen expressed the government's commitment

at the first national workshop on the problems of drugs in Cambodia.

"Drug-using people are suffering from a disease that they have no idea how to

heal," Hun Sen said. "In accordance with the drug control law of Cambodia,

drug addicted people must have regular consultation, treatment and rehabilitation

rather than being taken to court," Hun Sen said.

Despite such rhetorical commitments, actual treatment options for Cambodia's drug

addicts remain scarce, and they are subject to widespread and deeply rooted social

discrimination.

"Drug users are the most marginalized, oppressed, and discriminated group in

society," said Holly Bradford, founder of Korsang. "They have nowhere to

go. They are on the street and they are dying on the streets. They receive 100 percent

pure abuse - addicts are at the bottom of the pecking order."

Bradford said that the mentality engendered by addiction discourages drug users,

such as Hope, from asking for medical help.

"Addicts will wait until the last possible minute before seeking treatment,"

she said. "They don't believe they deserve treatment. Healthcare is not even

in their realm of possibility."

The government's acknowledgment that drug users have a right to treatment is laudable

said Graham Shaw, WHO technical adviser, but a lack of resources hampers their ability

to provide such services.

"There is a pile of political will in Cambodia to develop good treatment,"

he said. "The government is aware of the problem and would like to do something.

They are learning from HIV; they have seen that in other countries ignoring the spread

of intravenous drug use can undo all the good achievements of HIV reduction work

in the sex industry."

But while some target groups - street children, IV drug users - are able to access

treatment through NGOs such as Korsang and Friends/Mith Samlanh, for drug users who

do not fit the NGOs' criteria, there are few options.

Consequently, the concerned relatives of Cambodia's drug addicts are turning to any

available treatment regimes. One example is the "bootcamp" at Sisophon

where patients are subjected to military-style physical training regimes that one

expert referred to as "monkey-bar rehab."

Such hard line approaches, however, have been proven in Thailand and Vietnam to have

relapse rates of 100 percent, and infringe on the human rights of patients, said

Martin Lutterjohann, German Integrated Expert at the NACD.

"At the military 'bootcamps' the agreement is signed with the parents, not the

addicts," he said. "It is all voluntary, they have not been sent there

by court order," he said. "Technically, if someone then decided to leave,

it would be a violation of their human rights to force them to stay. However, [staff]

go out, chase the patient and get them back - then all the other residents of the

center give them a beating. And they explain this practice - they don't think anything

of it."

Although they lack both resources and training, police and the military are the first

option for the parents of young drug users, Shaw said.

"The police are the automatic default for concerned parents and guardians,"

he said. "The police are inundated with parents bringing in young children with

drug abuse problems as they have nowhere else to go, there are no other options.

The police can't cope with the volume of addicts they are receiving."

A recently released WHO report states that "there is currently no legal definition

as to what constitutes 'authorization' for persons to provide drug treatment and/or

rehabilitation in Cambodia."

WHO officials said this has caused some conflict regarding what can be described

as "treatment."

"The Ministry of Social Affairs believes that what the military is doing is

illegal," Shaw said. "They have said they cannot refer to the bootcamps

as 'rehabilitation.'"

But the popularity of such approaches in Cambodia is in line with regional perceptions

about what constitutes appropriate treatment, according to Lutterjohann.

"The Cambodian people do not have a sensitivity to human rights violations -

they think that it is good the military police instil discipline into these addicts,"

he said. "This is a manifestation of the same attitude I have seen in Thailand

and Malaysia. People like the 'bootcamp' mode of treatment. In Hanoi they built a

centre which isolates people from their networks and routine. They are physically

kept in the treatment centre for two years. This is too long. And there is no re-entry

- no gradual reintegration."

The pervasive belief in harsh institutional regimes as a cure for serious drug addiction

is misplaced, said Shaw, who cited Thailand and Vietnam's recent about-face in approach

to drug treatment as apt examples.

"Internationally it has been shown that [bootcamp-style treatment] does not

work; the relapse rate from such centres is 100 percent," he said. "This

approach has not been successful in Vietnam and is in fact now being reconsidered.

There is a shift in Vietnam from an institutional approach to a community-based approach.

Now the Vietnamese are interested in aftercare and reintegration. They have seen

that the relapse rate improves if you can get former residents to attend follow-up

classes."

Although elements of Thailand's drug policies have provoked much international concern,

Lutterjohann argues that Cambodia could learn from its successes.

"Cambodia can learn lessons from the Thai war on drugs," he said. "Although

there were some very bad things - such as the extrajudicial killing of over two thousand

people - there were some very good things. The drugs wars mobilized local communities

and called on schools and pagodas to do something, to contribute, to help."

Yet in Cambodia, local communities continue to exclude drug addicts. Pak Nyne, a

Korsang employee, explains that for the IV users they work with, the NGO's drop-in

center is the only place they have.

"When this place [Korsang's drop in centre] closes these people are sleeping

on the streets. They just have nowhere to go, they don't know who to reach out to,"

Nyne said.

The lack of facilities, either community-based or institutional, is compounded by

the fact that currently, internationally recognized treatments for some addictions

- such as methadone, used for stabilising heroin addicts - are not available in Cambodia.

Instead, the harsh exercise regimes or total isolation - from drugs, social networks,

the outside world - provided by bootcamp treatment, are considered sufficient, Shaw

said.

"The bootcamps do not offer detox services, they offer cold turkey," he

said. "This can be medically dangerous depending on the drugs used and the state

of the addiction, but it is certainly uncomfortable. An exercise regime will help

but there are more humane ways of treating people."

The introduction of methadone into Cambodia would, Bradford argues, provide both

a humane way of chemically detoxing drug users, and help reduce drug-related crime.

"When you are maintaining someone with methadone they don't have to go hustle

or steal to support their habit," she said. "If we bring methadone into

this country you will see a significant decrease in injection-related crime."

But treating the chemical side of drug addiction is only one part of solving the

problem, Bradford said.

"None of them [Cambodian drug addicts] have had any chance to get clean; of

course they want to get clean, it is all they want," she said. "But they

don't realize that when they are clean all the problems which drove them to take

drugs in the first place - poverty, family problems, abuse, peer pressure - will

all still be there."

Unless the life circumstances of the user are radically transformed, relapse is the

rule rather than the exception Shaw said.

"There is a 95 percent relapse rate globally following treatment," he said.

"This is largely because people return to drug-using environments."

Hope's personal story confirms the difficulty of preventing relapses.

"I have stopped taking drugs a few times, but I have always started again,"

he said. "When I don't take drugs I feel I have no power, no control over my

life."

While he is fortunate in having now found employment at Korsang - where he will become

a peer educator and be trained to provide the NGO's risk reduction services - for

the majority, the possibility of a drug-free existence seems impossible unless alternative

opportunities are available following treatment.

"If you can fill the void the drug leaves then you will have some measure of

success," Bradford said. "If you can't fill that void then you won't."