A critical exploration of professional perceptions of harm reduction policy and

A CRITICAL EXPLORATION OF PROFESSIONAL PERCEPTIONS OF HARM REDUCTION POLICY AND PRACTICE IN VIETNAM By TUAN DUNG TRUONG A thesis submitted to Victoria University of Wellington in fulfilment of the requirements for the degree of Doctor of Philosophy Victoria University of Wellington 2019 Abstract Throughout the 1990s, Vietnam experienced a dramatic rise in the prevalence of HIV among people who use drugs. In response, Vietnam’s Ministry of Health implemented several legal and policy interventions in the name of harm reduction. However, perceptions about drug use, people who use drugs, addiction and the nature of official interventions are contested. For many Vietnamese officials, abstinence remains the dominant philosophy.

Drug use is considered a ‘social evil’ in Vietnam and people who use drugs face draconian controls and incarceration in the name of treatment and crime prevention. Against this background, this thesis explores how key stakeholders perceive harm reduction philosophy and how they apply it in policy and practice. Based on qualitative and quantitative methods, it presents findings from a survey with 250 respondents and 26 semi-structured interviews, all with professionals involved in responding to drug use in Vietnam. The thesis illustrates that these professionals prefer abstinence approaches, and often see addiction as the result of moral failings and brain diseases.

While some interventions in the name of harm reduction are accepted, they are firmly rooted within a narrow public health perspective. Professional misperceptions about the key principles and practices of ‘authentic’ harm reduction are widespread. Many professionals believe, for example, that harms can only be limited through reductions in the demand and supply of drugs, or that detaining people who use drugs in compulsory treatment centres is a form of harm reduction. These rationales have resulted in continuing police crackdowns, and the use of ‘pseudo’ harm reduction strategies to control and punish people who use drugs.

Meanwhile, there are limited official attempts to address problems experienced by people who use drugs, like social isolation, stigma, discrimination, human rights violations, or problems of community reintegration. In conclusion, while a harm reduction rhetoric is regularly employed in Vietnam, ‘pseudo’ harm reduction strategies are carried out. i ii Acknowledgements This study has been a long time in the making. Many people and organisations have generously helped me over four years in my PhD journey.

First and foremost, I would like to express my respectful gratitude to my primary and second supervisors, Professor Elizabeth Stanley and Dr Fiona Hutton for their tremendous support and encouragement throughout my study process. I am especially indebted to my former supervisor, Associate Professor Julian Buchanan who has been an endless source of strength and inspiration that nurtures my dream of becoming a harm reductionist. Additionally, I would also like to express my profound gratitude to Kirsten and Deborah from Student Learning for their helpful feedback and invaluable recommendations during my study. I would like to express particular thanks to the Ministry of Public Security, the 911 Vietnamese Project and Victoria University of Wellington for funding my PhD study.

My appreciation also goes to the Faculty of Graduate Research for the financial support provided to me to do fieldwork and attend conferences. Thanks also must go to Head of School Professor Brigitte Bonisch-Brednich, administration staff and the Student Learning team for their enthusiastic support throughout my studies. I would like to thank all the study participants, who gave up valuable time to be interviewed. Thanks also must go to my colleagues at Police College and my leaders, Professor Khien, Mr Khoi, Mr Tao and Dr Em, for tremendous support and useful assistance.

Thanks to my friends, Brent, Max, Sarah and Reena, who share the same PhD endeavour, for their psychological support and encouragement. I particularly thank my friend, Hoe, for his inspiration that fosters me to research harm reduction in Vietnam. Also, I would like to thank other friends, Dr Hai, Dr Thu Vuong and Dr Tinh for their academic support. I would like to thank Madeleine for proofreading my thesis.

Last, but not least, this PhD is sincerely dedicated to my parents, my brother and other family members. Their wholehearted support encouraged me to pursue my goal and accomplish this thesis. iii iv Table of Contents ABSTRACT. III TABLE OF CONTENTS .V LIST OF ABBREVIATIONS.

IX LIST OF TABLES. X LIST OF FIGURES. XI LISTS OF IMAGES. 1 Vietnam’s Responses to Drug Use.

3 On the Rise of Harm Reduction. 6 Objectives of the Study. 12 ABSTINENCE: A GLOBAL RESPONSE TO DRUG USE. 17 The Notion of Drugs.

30 Brain Disease Model. 34 Psycho-social Model of Addiction. 41 Responses to Drug Use. 42 Abstinence and Relationships of Power.

46 Counterproductive Effects of Enforced Abstinence. 49 FROM ABSTINENCE TO HARM REDUCTION. 51 Brief History of Harm Reduction. 52 Defining Harm Reduction.

54 ‘Pseudo’ Harm Reduction. 55 ‘Authentic’ Harm Reduction. 56 Key Principles of Harm Reduction. 57 v The Conceptualisation of Drug Use.

57 Responses to Drug Use. 59 Harm Reduction and Relationships of Power. 61 Harm Reduction, Human Rights and Drug Policy Reform. 62 The Positive Outcomes of Harm Reduction.

65 Critiques and Challenges of Harm Reduction. 73 DRUG USE IN VIETNAM. 77 Negative Perceptions of Drug Use from History. 78 Political and Social Constructions of Drug Use.

81 Drug Use inevitably Leads to Addiction. 83 Drug Use Causes Crime. 86 Contemporary Drug Use Problems. 89 Definition of ‘Drugs’ and ‘Harm’.

98 RESPONSES TO DRUG USE IN VIETNAM. 101 The International Context. 110 Anti-Drug Education Campaigns. 112 Harm Reduction in Vietnam.

117 A Chronology of Harm Reduction in Vietnam. 118 Harm Reduction Interventions. 127 METHODOLOGY AND RESEARCH METHODS. 149 vi FINDINGS ON PERCEPTIONS OF DRUG USE.

152 Myth One: Illicit Drugs Are the Most Harmful. 152 Myth Two: Cannabis Causes Death. 153 Myth Three: Recreational Use of Illicit Drugs Is Impossible. 154 Myth Four: Illicit Drug Use Inevitably Leads to Addiction.

156 Myth Five: Illicit Drug Use Causes Crime. 165 People who use drugs. 174 Drugs and People who use drugs as the Key Harms. 174 Wider Harm Perspectives.

177 FINDINGS ON RESPONSES TO DRUG USE. 184 Controlling People who use drugs. 187 Compulsory Treatment Centres. 204 FINDINGS ON HARM REDUCTION IN VIETNAM.

207 Myths about Harm Reduction. 208 Understanding Harm Reduction. 210 Public-health Perspectives. 211 Attitudes towards Practical Interventions of Harm Reduction.

213 Sterile needles and Syringes. 216 Clean Injectable Drugs. 219 Drug-consumption Rooms. 220 Barriers to Implementing ‘Authentic’ Harm Reduction.

222 Insufficient Financial Resources. 222 Limited Understanding of ‘Authentic’ Harm Reduction. 224 Social and Cultural Factors. 225 Discrepancies in Relevant Laws.

228 Stigma and Discrimination. 229 vii Moving Forward. 230 The Closure of Compulsory Treatment Centres. 232 Reforming Legal Frameworks.

234 Acknowledging People who use drugs’ Rights. 235 Addressing Social and Economic Disadvantages. 237 DISCUSSION, IMPLICATIONS AND CONCLUSION. 239 ‘Pseudo’ Harm Reduction in Vietnam.

239 ‘Authentic’ Harm Reduction. 243 Implications of the Study. 247 Lessons from Drug Reform Changes. 248 Policy Recommendations for Vietnam.

256 The Strengths of the Thesis. 260 Research Limitations and Future Research. 299 Appendix One: The Differences Between Abstinence Based and Based Harm Reduction Approaches. 299 Appendix Two: Vietnamese Illicit Drug Schedules.

301 Appendix Three: Survey Questions. 302 Appendix Four: Surveyed Units. 305 Appendix Five: Interview Questions. 306 Appendix Six: Ethics Approval.

308 Appendix Seven: Consent Form. 309 Appendix Eight: Information Sheet (Interview & Survey). 310 Appendix Nine: Demographic Information of the Survey Participants (n=250). 313 Appendix Ten: The Survey Results (n=250).

315 viii List of Abbreviations ASEAN The Association of Southeast Asian Nations ATS Amphetamine-type Stimulants ART Antiretroviral treatment NSDPs Needles and Syringes Distribution Programmes MOH Ministry of Health MMT Methadone Maintenance Treatment MOLISA Ministry of Labour, War Invalids and Social Affairs MPS Ministry of Public Security NGOs Non-Government Organisations PWID People who inject drugs PWUD People who use drugs UN United Nations UNAIDS Joint United Nations Program on HIV/AIDS UNODC United Nations Office on Drugs and Crime WB World Bank WHO World Health Organisation ix List of Tables Table 4.1: Trend in use of selected drugs in Vietnam, 2011–2015 (UNODC, 2017, p.2: Seizures of selected drugs in Vietnam, 2011–2015 (UNODC, 2017, p.1: The work setting, gender and work location of survey respondents (n=250).3: The initial and changed questions on compulsory treatment centres. 145 x List of Figures Figure 4.1: Drugs ordered by their overall harm scores (Nutt et al., 2010; Nutt, King, Saulsbury, & Blakemore, 2007) .1 The development of Vietnam’s drug policies .2 Estimated cultivation of opium (1990 to 2016) (Luong, 2017; MPS, 2015).3 The number of methadone patients in Vietnam (2008–2017) .1: Some illegal drugs are less harmful than alcohol and tobacco .2: Cannabis overdose deaths are a problem .3: Most people who take drugs do so recreationally and rationally .4: Taking drugs will inevitably cause drug dependence .5: Drug use is a crime problem .6: Drug use is a public health issue .7: Drug use is a normal human behaviour .8: People who use drugs need to quit all drugs and stay drug-free .9: Drug relapse should be viewed as a learning experience .1: We can protect society by eradicating the supply of drugs .2: We should create a society free from drugs .3: We can protect society by punishing drug possession .4: People who use drugs need to be forced to get treatment .5: People who use drugs need to quit all drugs and stay drug-free .6: Compulsory treatment is effective in preventing drug relapse .7: People who use drugs should play a central role in deciding their treatment goals .8: Abstaining from drugs is the only effective treatment for people who use drugs .1: Oral methadone is effective treatment for people who use drugs .2: People who use drugs should be provided with sterile needles and syringes .3: People who use drugs should be provided with naloxone (an opioid antidote) to reduce fatal overdoses .4: Medically supervised rooms (drug-consumption rooms) should be available. 221 xii Lists of Images Image 1.1 Drug flows to Vietnam and the rest of the Southeast Asia region from the Golden Triangle area (Luong, 2017). 112 xiii xiv Introduction Situated close to the ‘Golden Triangle’ region, and lying across important South-East Asian region traffic routes (See Image 1.1), Vietnam has a long history of producing and consuming drugs.

The most common drug is opium, which was first introduced into Vietnam around the 1600s by migrant minorities from China (Luong, 2017), and consumed among ethnic minority groups in the northern mountainous areas. The level of opium production and consumption remained fairly limited, before demand and supply gradually increased during the 19th and 20th centuries, especially after the annexation of Vietnam by France in 1858 (Windle, 2012). Opium use then spread into other highland areas. In the early 20th century, the newly installed colonial government promoted the production and sale of opium in Vietnam for financial purposes, and for population control (Edington & Bayer, 2013).

The negative attitudes among Vietnamese people towards drug use have emerged from the historical actions of colonial governments. Drug use was first seen as a ‘national enemy’ because the French used opium as means to control, and even poison Vietnamese people (Rapin, Dao, and Pham (2003). Following Vietnam’s independence in 1975 (after the first and second Indochina Wars 1), the country had to deal with a great number of citizens who remained dependent on drugs (roughly 200,000 drug users) (Pham et al. Drug use was then seen as a leftover of the old regime and a form of external contamination from the west (Edington, 2016).