Exploring the limits of harm reduction – could we develop a good practice guide for corporal punishment of drug users?

Citation

(2011), "Exploring the limits of harm reduction – could we develop a good practice guide for corporal punishment of drug users?", Drugs and Alcohol Today, Vol. 11 No. 2. https://doi.org/10.1108/dat.2011.54411baa.002

Exploring the limits of harm reduction – could we develop a good practice guide for corporal punishment of drug users?

Article Type: Editorial From: Drugs and Alcohol Today, Volume 11, Issue 2

In the mid 1990s, harm reduction was adopted as a governmental health strategy against the visceral opposition of one of its main architects, the secretary for health. Brian Mawhinney, an Ulster protestant was a man of religious conviction who was trying to translate moral principle into public policy. He was deeply opposed to the use of mind altering drugs and the life style that surrounded it. In contrast to many policy makers who privately hold the policy of prohibition in disdain but acquiesce to it in public, Mawhinney was a fervent believer in the righteousness of the abstentionist cause. The programmes that had been pioneered by his predecessor, providing needles and syringes to injecting drug users, appalled him. He saw them as condoning, and even giving a stamp of official approval to a form of behaviour that he regarded as deeply immoral. He, therefore, commissioned research to establish whether these services achieved any positive outcomes in preventing the spread of infections. When these furnished evidence that genuine health benefits were to be gained he agreed to support them against his better judgement.

After 15 years, harm reduction as a strategy and the various practices it comprises, have been adopted by health departments in many countries the world over as well as by the leading international agencies including the World Health Organisation. But neither the individual activities nor the underlying precepts are met with unconditional approval by the general public, where large sections hold a dim view of illicit drugs and regard any of the subsequent problems as a self-inflicted injury. Many think that drug users should not be afforded help from the public purse, but be compelled to change. In some parts of the world these less charitable sentiments are shared by some of the very people in charge of services providing for drug users.

Across Southeast Asia and China, for example, the most popular method for dealing with addicts is to confine them to boot camps for long stretches of time, where inmates are put through their paces to “sweat out” the badness. The daily programme of assault course exercise, drills and manual labour is complemented by an array of punishments that include beatings, lock ups and forcing people to hold uncomfortable positions. A couple of reports published at the end of 2009 exposed the gruesome conditions of Cambodian compulsory treatment centres (Open Society, 2010; Human Rights Watch, 2009). They illustrated in graphic detail how a regime based on brutality as a form of medical method provides opportunities for further abuse by the different people working there. While it was difficult from the descriptions provided to discern any activities that could be considered as “treatment”, punishment, humiliation and exploitation of inmates were regular features and entrenched.

As violence is the salient feature of these ostensibly therapeutic establishments, it is important to gain a closer understanding of the underlying motivations and to distinguish between different forms. When people try to escape or break the rules of the centre, for example, the violent response by the guards is a punishment. It is severe and justified in terms of maintaining discipline, deterring others from following and is a way of ensuring adherence to the “treatment” regime. The systematic humiliation of patients, on the other hand, can be argued to have a therapeutic function, which is also used by some of the more hardline treatment providers, for instance, Daytop borrows much from the military. A key principle is to break the individual, in order to build them up again, as healthy, drug free members of their therapeutic community.

As both punishment and therapeutic humiliation employ similar methods the motivation and disposition of the staff has to be scrutinised to distinguish and evaluate effectiveness and therapeutic benefit. Could it be that the punishment is meted out as part of a punitive care plan, with a dosage of pain and discomfort titrated to the assessed needs of each individual patient? Is it administered with professional detachment, even a regretful sigh reminiscent of nineteenth century school masters whipping recalcitrant boys with a plea of “this hurts me more than it hurts you”? Such methods, however, deplorable may score well against some outcome criteria. Yet, from the available information, it seems that far from forming part of a therapeutic rationale, punishment was administered on a whim. Not only was there no treatment plan, there were no treatment staff, as the camps in Cambodia are run by different branches of the armed forces. Violence was employed not as part of a wider care plan, but is a spontaneous decision by poorly trained soldiers. They had no understanding of drug use other than that the vagaries of the law had rendered these people into their power.

According to these two reports then much of the punishment appears unsystematic and random, determined more by the moods of guards than the therapeutic intent of carers. In many cases abuse merges with straightforward exploitation, where guards hold inmates or their families to ransom, or obtain sexual favours and in some cases even act as their pimps in Cambodia’s flourishing “entertainment industry”.

Cambodia is still working its way out of a dark chapter in its history and remains heavily dependent on development assistance from the international community. This allows international researchers and journalists a degree of access to penal establishments and creates opportunities for holding the authorities to account. Human rights organisations enjoy no such leverage in powerful, fast growing countries like China or Malaysia. Criticism of such practices is often dismissed as a peculiar Western concern with human rights, that sounds all the more hollow after the well publicised abuses in Guantanamo, Abu Ghraib and the use of torture by Western secret services in third country locations. Organisations that are better placed to negotiate changes in approach, such as the United Nations Office on Drugs and Crime or the International Narcotics Control Board (INCB) have not taken up this issue, remarkable in the case of the latter, as it does take a detailed look at domestic practices. The INCB has, for instance, taken time to take the UK Government to task for downgrading cannabis from class B to C, or the Canada for allowing heroin injections in drug consumption rooms. Yet no protests are lodged against the inappropriate and counterproductive use of corporal punishment, presumable as this would pose an unwarranted intrusion into the internal affairs of the country in question.

According to Eka Iakobishvili of the International Harm Reduction Association, there are some 23 countries today that routinely apply corporal punishment against drug offenders. Justifications vary from the therapeutic to the punitive, and often contain elements of both. They all involve various forms of whipping, caning, flogging with a variety of implements. While many campaigners take a view that these practices are barbaric and should be stopped altogether, there is an argument for extending the principle of harm reduction to this obscure corner of the drugs field. In Malaysia, for instance, the “patient” to use the medieval term for people being subjected to torture, is strapped to a wooden board, with his backside exposed to the lash. The flogger then extends his arm as far as it will go to get maximum purchase and strikes down with full force. It only takes a few lashes for the skin to break, and after the administration of several dozen the flesh is cut into a mushy pulp.

Contrast this with the flogging regime of Northern Nigeria, where local interpretations of the sharia law prescribes that the flogger hold a copy of the Koran under the arm that holds the whip, which prevents him from extending it to full length. In many cases, then, the stroke comes from the wrist and inflicts very little pain, and no damage to the flesh. The real purpose of the punishment is humiliation, not dissimilar from the bright-coloured uniforms worn by US prisoners. Though the practices appear abhorrent to Western readers raised in a tradition where the body is sacrosanct and the standard forms of punishment are the deprivation of liberty or wealth, the practicalities of the sharia court have to be read in the cultural context. In Nigeria, as in many other countries, the criminal justice system is slow and corrupt. Offenders once arrested find themselves locked up for long periods of pre trial detention. The outcome of the trial, the sentence and prison conditions are often determined by the family’s ability to pay judges, jailors and police officers. The sharia courts have a far better reputation for impartiality, they are speedy and physical punishment may well be preferred to indeterminate incarceration.

Campaigners for legal reform may choose to argue that the emphasis should fall on improving the conventional legal system, by speeding up processes and stamping out corruption. But such idealism does not help resolve the immediate problems for criminal justice in the here and now. It also, interestingly, overrides the function of local autonomy by superimposing a greater, absolute set of values. But the right to preserve the body from short-term pain is not inalienable, and where individuals take the informed decision to trade in the pain of a quick flogging for the freedom they gain by escaping long-term detention who are international campaigners to prevent them?

The question is if short-term benefits, in this case a less bad form of justice should be sacrificed in the pursuit of a higher, long-term aim of greater justice. Recent developments in Western countries, such as the relentless rise in prison populations and the return of torture have eroded any remaining optimism that these goals are inevitable or even attainable. A pragmatic approach would, therefore, be to work with the means available in each given circumstance, which in the case of the 23 above mentioned nations means with the reality of corporal punishment as an ongoing practice.

If, without validating the principle of corporal punishment, we accept their factuality, is it, therefore not better for the harm reduction community to engage with the floggers and work towards ways of reducing the harm? A starting point would be to argue that both forms of corporal punishment described above, the lethal whip and the light tap on the backside are equally effective modes of deterrence. The Nigerian patient will be able to move on and reconstruct himself with his body intact at the end of his ordeal. In Malaysia, on the other hand, the severity of the punishment destroys the drug user’s body and leaves him in the words of the eighteenth century reformer Benjamin Rush “lost to society”. So, arguably, is the professional flogger.

What is therefore proposed is to engage with the relevant authorities of countries where corporal punishments is used to develop a code of good practice for floggers, whippers and caners. There should be a resolution that the purpose is to reform and deter, to which end the application of pain is secondary. It is the humiliation of punishment and the process itself that are the penal instruments, not the degree of pain itself. We suggest that there should be guidelines detailing practical steps such as the requirement for the flogger to hold a heavy object under the arm to prevent striking with an outstretched arm. There should be a limit to the number of strokes that can be applied.

Learning from history there is a danger that making penal processes less cumbersome leads to their being used more extensively. The guillotine made for a far more humane and painless method for beheading, but also allowed for executions to be held en masse, a consequence that the humane and compassionate Dr Joseph Guillotine had not anticipated. The good practice guide for corporal punishment, therefore, has to stipulate that a number of procedures are met, including the discussion of alternatives, the establishment of guilt, and a procedure, which is highly ritualised and awkward to set up. Public participation is problematic, on the one hand, it is likely to effect a restraint on the flogger, on the other it will intensify the humiliation of the patient. It has to be remembered that the purpose of flogging as of every other punishment is rehabilitation, the teaching of a lesson, so some form of ritualised expression to this notion needs to be thought of. Closer scrutiny of methods in current use may allow for an exchange of good practice.

More difficult is the role of the flogger. In effect, society delegates onto a designated individual the unethical task of inflicting wilful violence onto someone who to all intents and purposes has done nothing to them. Multiple ways to counter this dilemma have been devised for executing capital punishments, none of them satisfactory. The shooters in a firing squad know that one of the bullets handed out is a blank, and can comfort themselves with the thought that it was not them who were responsible for killing the condemned man. In the US lethal injection is such a popular form of execution precisely because it is so highly mechanised, allowing all who participate to claim that they merely pressed a button. The downside of introducing additional steps into the causal chain, or creating uncertainty by spreading responsibility is that a larger number of people are involved in the unpleasant task of killing.

The mechanics of flogging do not quite allow for the same kind of task sharing, which leaves the actual execution of the punishment with a dilemma. Hitting someone who has done nothing to you and committed a victimless crime is not something that right-minded people engage in lightly. There is then some concern about the people who do step forward to carry out these tasks. One serious problem is that these positions are colonised by people who gain perverse pleasure in the infliction of pain, with the risk that the legal process of objective punishment is mingled with the subjective gratification. One way of ensuring that the dignity of the law is not compromised, is to monitor all floggers for signs of penile tumescence. Any sign of arousal should automatically lead to disqualification. Mechanical contraptions could of course be developed, but until an industry wide standard has been agreed on it would suffice for the floggers to carry out their duty in their underpants.

Flippant though this may sound, there is a serious theme about engaging with a problem on territory that is antithetical to one’s own convictions and principals, but doing so for a greater good, in this case, the physical well being of the people subjected to corporal punishment. For those unlucky drug users (or any other petty offender for that matter) sentenced to a flogging the difference between the Malaysian lash or the Nigerian tap is far more important than the prospect of abolition at some undefined point in the future. For the harm reduction community the objections are twofold, both ethical and political. Engaging with the floggers is simply distasteful, and any amelioration of the practice itself may just appear as condoning the practice.

Yet many harm reduction advocates have gone along with the introduction of drug treatment in prison. Indeed, rolling out prison-based interventions became a flagship policy of the previous government, with enthusiastic “buy in” from many HR activists. The arguments for getting involved with the criminal justice system are that this is a good opportunity to help vulnerable people into behaviour change, and that it helps improve the situation of drug users in prison. But far more intrusive and repressive measures have been strapped onto the back of treatment, such drug testing, cell searches and tougher checks on visitors. Most controversial though has been the implicit collusion with a policy principle that certainly runs counter to the editorial position of this journal: that incarcerating people for drug us is legitimate. Why then, deny the same humane intervention to those who are unfortunate enough to suffer physical punishment for their use? Comment invited.

In this issue

From the start, DAT has worked hard at being an inclusive journal, reaching out to a readership across different professional domains. In that vein of inclusivity we have extended the discussion to substances that are not always the most conventional encountered in drug use surveys or treatment centred. In this issue, we are moving into hitherto unexplored territory with Dawn-Marie Walker and Hercules Eli Joubert’s paper on anabolic steroids. The methodologically sound exploration of a small but entrenched subculture provides more detail on the rich fabric of substance use across a spectrum of social settings, and the ongoing process of drug use “normalisation”. The paper situates substance use within different debates on the construction of masculinity, concerns with body image and the role of the media in determining notions of beauty. Most interestingly, is the seeming contradiction between the ideal of health promotion on which the gym and work out subculture is based, and the resort to a little chemical help, which possibly accounts for the relative secrecy in which the phenomenon is shrouded.

It is more of a mystery that attaches to the use and discussion of ibogaine, which as readers of this journal will be aware (Brackenridge, 2010, p. 4; Wells, 2007, p. 2) is used increasingly outside traditional settings for therapeutic purpose. James Rodger provides a historic review of the “discovery” of Ibogaine by Western drug researchers, and its contemporary application in treatment. It remains controversial but is very attractive to a particular cohort of clients who have tried unsuccessfully to improve their lives with other treatment modalities. For Rodger, the discussion goes beyond Ibogaine to the resurrection of “psychedelic therapy from the graveyard of medical charlatanry”.

Strong words are also used in Alain Braillon and Gérard Dubois’s polemic against the tobacco industry from the development of “ammonia technology” as a tobacco additive to the promotion campaigns stretching back for over a century. What is of interest to DAAT is how this perspective on an industry impacts on the wider discussion of drug regulation. The editorial position has long advocated that we should abandon the criminalisation of drug production and use and move towards a regulated framework. The experience of the tobacco industry shows what difficulties one has to contend with once that approach is taken. Yet there is another dimension to this, which should serve as a salutary warning – if the distribution of habit forming substances is left to profit-based private sector corporations then the likely outcome will be product degeneration, with maximum public health harms just as TOX-bacco.

Mark Govier continues the journal’s series of papers (Davey et al., 2010, p. 3; Measham et al., 2010, p. 1) on Legal Highs with a detailed discussion of research chemicals in response to increasing government concern on what goes into these compounds. The paper questions the suitability of the 1971 Misuse of Drugs Act, and indeed the Advisory Council for the Misuse of Drugs at a time of increasing trend to manufacture and experimentation and concludes that, it is “preferable that ‘Generation Meph’ have access to some form of evidence-based information about what they consume than none”. In a different context, Marie Claire van Hout and Rebekah Brennan explore the attitudes of young people towards substances and risk.