Her first husband was a drug user who sometimes earned money from drug dealing. While he struggled with his addiction, Veni was left to find ways to provide for her family. After 15 years Veni finally ended the marriage as she felt she couldn’t be her husband’s ‘guardian angel’ any more.
The
experience of coping with her ‘junkie’ ex-husband had a profound impact on Veni
and in 2008 she became involved in harm reduction, a global intervention
program aimed at minimising the medical and social problems associated with
illegal drug use. It does this by encouraging the use of legal substitution
drugs, like methadone and subuxone, and distributing free clean needles and
condoms.
Veni’s
involvement in harm reduction started when she was invited to give a
testimonial as the wife of an injecting drug user (IDU). Soon after, she was
recruited by several non-government agencies (NGOs) in Jakarta to do outreach
work meeting with drug users, distributing clean needles and referring those
who want access to treatment. She has found outreach work a positive way to
share her experience of living with a drug user while, at the same time,
earning enough money to provide for her children. Veni believes that she is not
only helping drug users and their families but also helping to manage the emotional
pain and trauma of her past.
Incubation period
After the
first case of HIV/AIDS was identified in Bali in 1987, Indonesia started one of
the largest harm reduction programs in Asia. Focusing upon one of the highest
risk groups, IDUs, harm reduction has come to dominate efforts to impede the
spread of HIV/AIDS. The first case of HIV transmitted via unsafe drug injection
was reported in 1995, by 2005 unsafe drug injection caused 38.9 per cent of
total reported cases. Some scholars believe that the number of drug users
increased significantly after the fall of the Suharto regime in 1998 due to a
combination of the impacts of economic collapse, high unemployment and an
upsurge in social and political violence. The numbers of intravenous drug users
are still growing.
Post-Suharto
presidents have introduced limited measures to try and stem this. During the
presidency of Megawati, for example, a memorandum of understanding was signed
between the National Narcotics Board and the National AIDS Commission in
response to the increasing number of IDU-related HIV cases. Methadone therapy
was introduced for putau (low grade heroin) dependencies in Jakarta and Bali.
In 2004, the Yudhoyono administration successfully sought international funding
to create an IDU Intervention Unit which managed 22 NGOs and two Health
Ministry programs across six provinces. By the end of 2006, a decree from the
Ministry of Health had established guidelines for harm reduction
implementation. The government's support for methadone therapy programs was
also reflected in subsidies and the establishment of methadone treatment in
some community health centres.
Despite
these measures, studies examining harm reduction implementation in Indonesia
have identified significant gaps between rhetoric and practice. Perhaps most
alarmingly, instead of reducing addiction as intended, harm reduction measures
have often resulted in new poly-drug dependencies involving combinations of
prescribed substitution drugs. Lack of adequate information and supervision has
made it harder for IDUs to manage substitution drug use while struggling with
their dependencies to illegal drugs. Many IDUs are using both methadone and
anti-depressants – mostly without supervision of a doctor – in order to achieve
their desired physical and mental states. This is prohibited within the
treatment regime as harm reduction, in order to be successful, demands that
only methadone is used.
High-risk moment
Veni and
her friend Maulana* started talking about these impacts of harm reduction
implementation during an outreach annual meeting in December 2014. The
conversation began from their shared pessimism regarding what’s been achieved
to date and what still needs to be done. ‘What is harm reduction really trying
to accomplish? We have been doing this work for more than ten years, but drug
users are still vulnerable’ said Veni. Despite harm reduction programs having
run for so long there remains a lack of basic support services for drug users.
The main
focus of current harm reduction programs is the distribution of clean needles
for IDUs. This is related to the government’s national action plan that at
least 30 per cent of the country’s IDUs should have access to substitution
drugs, and 70 per cent should have access to sterile needles. However, another
important goal of the harm reduction program – to improve the socio-economic
conditions of IDUs’ – continues to receive little attention and few resources.
IDUs face
a number of difficult challenges in finding work and participating in treatment
programs creates further impediments as most treatments are held during office
hours. Providing take-home doses has been used as one means of overcoming this
problem; however, difficulty in finding and keeping regular employment is part
of a vicious cycle for IDUs participating in harm reduction programs.
Package of subuxone purchased from one of the private
clinics in South Jakarta
Uncertainty
over job security and the sustainability of existing programs has also been
felt by outreach workers. The HIV Cooperation Programme in Indonesia –
Australia Aid (or HCPI–AusAid) has been the largest financial support body for
harm reduction; however, funding ended in December 2015. Veni and Maulana are
unsure about what the future holds. ‘We don’t know anything yet, all we know is
that we can still work until October’ said Veni. Maulana is more sceptical.
‘Without HCPI–AusAid, NGOs won’t be able to continue distributing clean needles
in Jakarta. Even the syringes for the harm reduction program in community
health centres are provided by HCPI–AusAid.’
The
benefits of clean needle distribution are limited not only by the termination
of HCPI–AusAid funding but also by the current Indonesian government’s
steadfast adherence to a ‘zero tolerance’ policy towards illegal drug use. Many
injectors are reluctant to carry clean needles with them for fear that police
would treat it as proof that they use illegal drugs. Thus, HIV prevention
programmes for IDUs are at risk because clean needles are no longer distributed
in user hot spots.
Although
the National AIDS commission still has stocks of syringes that can be used as a
buffer, these are said to be of low quality. Some users even prefer to use
second-hand syringes. Taufan*, a subuxone user, said ‘the pistons of syringes
from the AIDS commission are easily broken. They are useless for IDUs’.
President Widodo may have declared a national ‘Darurat Narkoba’ (Drug
Emergency), but this has not included the provision of necessary basic supports
for drug users.
With the
HCPI–AusAID coming to an end, the availability of syringes for IDUs is now at
stake. Most financial support for programs delivered by community health
centres comes from the national budget through the Ministry of Health, and this
is likely to be delayed due to a convoluted bureaucracy. According to
Presidential Decree No. 12/2013 regarding health insurance, treatment for
HIV/AIDS patients will continue to be provided, with the exception of
drug-related therapy. However, with minimal financial support from the
government for syringe exchanges and institutionalised discrimination against
drug users affecting their access to adequate health care, Indonesia is likely
to face greater problems.
Indonesia’s
current drug policy still puts many users through the criminal justice system,
with harm reduction based in a total abstinence paradigm implemented by
poorly-resourced rehabilitation centres. In spite of this, the National
Narcotic Board declared that it would rehabilitate 100 000 drug users by the
end of 2015. It is not surprising, considering the lack of sufficient
infrastructure, resources and qualified staff to run existing rehabilitation
centres, that this target was not reached. Moreover, it reflects the
government’s continued misunderstanding of the nature of addiction itself,
which cannot be adequately addressed while drug users continue to be
criminalised.
In the
words of Taufan, ‘Indonesia doesn’t really have any disaster preparedness; all
we’re doing is fighting against the fire. By the end of the day, it’s all too
late.’ Does this mean we should say good-bye to Indonesia’s target of zero new
HIV cases by 2030?
*Not
their real names.
Sari
Damar Ratri
Sari Damar Ratri (sdratri@ekuator.or.id) is a
medical anthropologist at Yayasan Ekuator, a research foundation that focuses
on the study of inequality and marginalisation in Indonesia. She is currently
working as media-communication manager at the Centre for Gender and Sexuality Studies,
Faculty of Social and Political Sciences, University of Indonesia. Her research
on harm reduction implementation in Indonesia was part of the University of
Amsterdam’s Chemical Youth Project funded by European Research Council (ERC).
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