UNGASS Women 2016: South & West Asia

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Drug-related offences are severely penalized in South and West Asian countries, and the death penalty for drug-related offences is upheld in most of the region.[1] Refugees escaping conflict zones, particularly in Iraq and Syria, are vulnerable to developing substance use disorders and to becoming involved in drug trafficking out of financial need.[2] Many countries in the region do not collect, or do not publish, data on the prevalence of drug production, trafficking and use.[3] Further, insufficient governmental control and general lawlessness in some parts of the region make it difficult to monitor drug control activities and the prevalence of drug use.[4] It is particularly difficult to assess women’s drug use and treatment needs where women generally remain at home and the stigma surrounding drug use is high. A need remains for better data collection on these issues in order to fully understand the impact of governments’ drug policies on women.

Services for drug users

Iran, Israel, Lebanon, Jordan and Syria’s national strategy documents on drugs and HIV explicitly support a harm reduction approach to drug use.[5] Harm reduction services such as needle and syringe exchange programs and opioid substitution therapy are available in Afghanistan, Iran, Israel, Lebanon, Palestine, the United Arab Emirates, India, Nepal and Bangladesh. Many other countries in the region, however, continue to promote drug abstinence only and remain politically opposed to introducing harm reduction initiatives.

Harm reduction services

There are approximately one million drug users in Afghanistan, 11% (110,000) of whom are women.[6] Overall annual prevalence of drug use is estimated to be 6.6%.[7] Although the number of treatment facilities in Afghanistan increased from 43 in 2009 to 108 in 2013,[8] access to services is low: only 10% of drug users have access to treatment services.[9] It is especially low for women: only 4% of female drugs users in Afghanistan have access to treatment services.[10] Because women’s drug use is highly stigmatized, there are fewer services for women drug users, and women are hesitant to access existing services for fear of having their drug use made public.

In 2013, Afghanistan adopted the National Drug Demand Reduction Policy 2012-2016. It aims to prevent vulnerable groups, such as children and adolescents, from becoming drug dependent, to reduce the social and health impacts of drug abuse on communities, to provide therapeutic and rehabilitation services and to conduct epidemiological research on drug use.[11] Working with national stakeholders, UNODC runs an HIV service delivery program across six provinces, targeting women who use drugs (injecting and non-injecting), women whose male spouses inject drugs and women in prison. Since 2008, the program has reached over 3,000 women who use drugs and almost 1,000 of their spouses who also use drugs.[12] Laila Haidari, an Afghan woman, sought to break the stigma around women’s drug use by establishing facilities for women who use drugs in Kabul, and opening a restaurant staffed by the facilities’ clients, allowing them to learn new skills and rebuild their lives.[13]

The International Narcotics Control Board reports that drug abuse is extremely problematic in Iran, but notes that data on its prevalence is lacking. In 2014, Iran’s Drug Control Headquarters estimated that 3 million people (of Iran’s population of 76 million) had substance abuse disorders, more than 700,000 of them women, although due to the stigmatization of drug use and people’s – especially women’s – desire to keep their drug use secret, it is difficult to assess the true prevalence of drug use and substance abuse disorders.[14] Since 2000, harm reduction services, including opioid substitution treatment and needle and syringe programs, have expanded in Iran and in 2014 Harm Reduction International reported that Iran had the highest level of needle and syringe exchange in the region, with 55-77 syringes distributed per person who injects drugs annually.[15] These services are now also available to incarcerated people.[16] In 2015, there were over 4,500 private and around 600 public drug treatment facilities in Iran, and the Government estimated that 750,000 people received drug treatment in 2015.[17]

Iranian women who use drugs are stigmatized, discriminated against and experience higher levels of HIV, Hepatitis C and other blood-borne viruses than Iranian men. Nevertheless, there are substantially fewer treatment services available to women.[18] The majority of women with substance abuse disorders have never received any treatment. In 2007, a methadone clinic specifically designed for women opened in Tehran, with services provided by a psychologist, a doctor, a midwife and a social worker. Almost 100 women registered for treatment during the clinic’s first year of operation.[19] By 2012, it had expanded to 27 sites around the country, although it is not known if these are still in operation. Evaluations of the clinics found that women responded well to the treatment: within six months of initiating treatment, decreases were observed in heroin use, levels of dependence, engagement in high-risk injecting behavior and criminal activity.[20] The clinics’ gender-sensitive settings and provision of services designed and operated for women was key to their success. Due to the social stigma attached to women’s drug use, however, most women fear seeking treatment for substance abuse disorders, and when they do, feel that they must do so in secret.

Launched in 2011, Lebanon’s opioid substitution therapy program served 1,375 patients in 2015, which was double the number of patients registered in mid-2013. The program also provides medical treatment, psychiatric evaluation and psychological and social assistance. Nearly 95% of patients are male and more than half are between the ages of 26 and 35.[21]

In May 2014, the Palestinian Ministry of Health opened a methadone opioid substitution therapy clinic in Ramallah. Prior to opening the clinic, health care professionals conducted a study and training visit to opioid substitution therapy facilities in Jerusalem. Just over a year after opening, the clinic had 52 patients.[22]

India and Nepal have implemented comprehensive HIV-prevention policies among drug users, including needle and syringe programs and opioid substitution therapy. After a successful pilot project in 2013, India expanded the methadone maintenance treatment program. Under India’s national AIDS control program for 2013-2014, 45 new opioid substitution therapy facilities for injecting drug users were established, doubling the number of such facilities. India’s department of AIDS control within the Ministry of Health and Family Welfare supports the provision of opioid substitution therapy services through over 150 dedicated facilities across 30 states and union territories in India.[23]

The Chanura Kol project ran in Manipur, India from 2010-2013, providing general and emergency care and support services to women who inject drugs, with the aim of decreasing the transmission of HIV and drug relapse amongst women who inject drugs. The project also provided income generation support to help women avoid relapsing, and filed cases on behalf of sex workers who had been the victims of violence at the hands of clients, police officers and pimps.[24]

Opioids for pain relief and palliative care are relatively inaccessible in South Asia, well below the world average. To make opioids more readily and legally available to patients who need them, India adopted the Narcotic Drugs and Psychotropic Substances (Amendment) Act in 2014, which introduced a simple and uniform regulatory regime for opioids for pain relief. The Act included provisions to improve treatment and care for people with substance abuse disorders, and legitimized opioid substitution therapy, maintenance and other tertiary services.[25]

Bangladesh’s HIV-prevention policy provides for needle and syringe programs and opioid substitution therapy. In 2014, 10,364 patients with substance abuse disorders were treated in private treatment facilities, up from 8,108 patients in 2013. However, women constitute a very small proportion of those receiving treatment: only 25 women received treatment in 2014.[26] However, successful treatment models have been implemented, and these should be replicated. In 2005, Family Health International Bangladesh established a program of free drug treatment services for women. Opioid substitution therapy was not available at the time, so treatment consisted of clonidine-assisted detoxification and three months of in- or out-patient care and follow-up. Women received HIV voluntary testing and counseling, screening for and treatment of STIs, information on HIV risk-reduction and Hepatitis B and C, and overdose prevention education. The program targeted homeless women with histories of drug-related harms. Services were provided by specially trained female staff members. The program also offered childcare, prenatal care and vocational rehabilitation, and treatment for male drug-using partners.[27]

Oman has no formal harm reduction program, but anecdotal evidence of small-scale, unofficial syringe distribution in the Muscat area was reported by Harm Reduction Internationalin 2012.[28]

Harm reduction in prisons

Punitive drug policies throughout the region have resulted in many people who use drugs being incarcerated, and injecting equipment is frequently shared in prisons throughout the region.  Despite this, in 2014, Iran was the only country in the region providing needle and syringe programs and opioid substitution therapy in prison settings. Improving access to TB and HIV co-treatment is also crucial to addressing the needs of the most marginalized people who use drugs.[29]

HIV testing for drug users is mandatory on admission to treatment and on arrest and imprisonment in several countries, including the United Arab Emirates, Iraq and Bahrain.[30]

Other approaches to drug use

In May 2015, the universal prevention curriculum was launched in Bhutan as part of the drug demand reduction program of the International Centre for Certification and Education of Addiction Professionals.[31]

The Nepal Drug Users Prevention Association, Nepal’s first-ever network of women drug users was launched in 2014 by UNODC and Dristi Nepal, an NGO based in Kathmandu.[32]

Iran, Jordan and Syria’s national HIV strategies now explicitly mention people who use drugs as a key population at higher risk of HIV. Syria’s 2011-2015 National Strategic Plan on HIV and AIDS prioritized prevention among populations at higher risk of HIV, including people who inject drugs.[33]

Turkey’s national policy and strategy document on drugs for the period 2013-2018 covers the activities of various ministries, public institutions and organizations in the pursuit of supply reduction, demand reduction, data collection and research, evaluation, coordination at the national level and international cooperation. The policy takes a new approach to demand reduction by treating substance abuse disorders as a critical public health issue, promoting prevention activities, supporting the medical treatment of substance abuse disorders, and prioritizing social reintegration activities.[34]

Jordanian governmental and non-governmental entities specializing in substance abuse disorder treatment are collaborating to create a national database on drug abuse. This will address the lack of reliable data on the extent of drug abuse, in order to facilitate the development of better-suited and tailored strategies.[35] In 2015, Jordan’s Security Directorate and Ministry of Labour entered into agreements to secure employment for inmates upon their release. This program included people incarcerated or in treatment for drug-related offences. The Jordanian social security system is also being broadened to include rehabilitation facilities.[36]

At a 2015 UN discussion on drugs and human rights, an Israeli representative stated: “Women [drug users] also have unique needs. Women-only services are important, as they have unique issues such as sexual abuse, motherhood, etc. Provide them tools to cope with issues such as prostitution and motherhood.”[37]

The Middle East and North Africa Harm Reduction Association, a network of governments, civil society organizations and researchers, was established in 2007, and has encouraged governments and civil society to pursue a harm reduction approach to drug use in the region.[38] In 2011, the International Drug Policy Consortium and the National Rehabilitation Centre in Abu Dhabi organized the first seminar on drug policy in the Middle East and North Africa region.

Law enforcement polices and their impact

Most countries in the region uphold the death penalty for drug-related offences. In Iran,[39] which conducts the second highest number of executions in the world (second only to China), hundreds of people are executed for drug-related offences every year, despite the government having admitted that this is having no impact on drug trafficking. In 2011, Iran's Supreme Council for Human Rights reported that 74% of people who were executed had been convicted of drug trafficking. Reprieve, a human rights organization, reported that approximately 600 of 947 people hanged in 2015 had been convicted of drug-related offences. This is the highest number of people executed for drug-related offences in 20 years. At least 31 people have been executed for drug-related offences in 2016. The people executed for drug-related offences are mostly ethnic minorities and members of marginalized groups. Despite these routine human rights abuses, the UNODC continues to fund Iran’s anti-drug efforts. Although women account for a small number of the people executed in Iran for drug-related offences, those who are executed tend to have been arrested for buying or selling small quantities of drugs.[40]

Women play an important role in opium poppy cultivation in countries such as Afghanistan and Pakistan. As education and most jobs are largely unavailable to women, opium cultivation can provide women with financial opportunities, allow them some financial independence, and sometimes establish them as their family’s primary financial provider.[41] Opium cultivation is often the only means of survival for many female-headed households. However, due to the illicit and unregulated nature of this industry, there are no appropriate mechanisms to ensure that farmers receive fair compensation for their goods; in Pakistan, the average income of households cultivating drugs’ is half of the national average.[42]

Further, opium cultivation puts farmers at risk of arrest and incarceration, and is not a sustainable career, with governments attempting to eradicate illicit crops. Afghanistan’s counter-narcotics policy has prioritized poppy-field eradication.[43] In 2015, the government eradicated 3,760 hectares of opium poppy fields.[44] Opium bans and crop eradication campaigns have led to large-scale displacement of people, forcing families and entire communities to relocate to more isolated and remote areas where they are less likely to be reached by the spraying planes. Crop eradication programs often destroy not only valuable illicit crops, but also legal food crops, which are usually farmers’ only means of subsistence, and have led to increasing indebtedness and poverty among poppy farmers, which has reduced their access to public services such as health care and education.[45]

The International Drug Policy Consortium attributes young Afghan ethnic minority women’s increased engagement in sex work and vulnerability to human trafficking to the eradication of opium crops.[46] The International Narcotics Control Board reports that some opium farmers have resorted to selling their daughters in order to pay off their debts.[47] While these eradication programs have serious consequences for women’s and communities’ livelihoods, they have had a negligible impact on opium production or the drug trade.[48]

Despite women’s key role in opium poppy cultivation in Afghanistan and Pakistan, most programs that address drug production only include gender components as ‘special considerations’, and have not properly addressed the importance of this industry for women. A need remains for mainstreaming gender considerations within policy development and program planning and implementation.[49]

In 2014, Bhutan registered 644 criminal drug cases, the highest number of drug cases ever registered by the authorities. Ninety percent of the offences in these cases were related to the possession of controlled substances. Cannabis was the most common drug of use.[50]

People who inject drugs are highly criminalized in Bahrain, with reports of arrests being made for possession of drug paraphernalia including new needles and syringes. A prescription is required in order to get needles and syringes, making it very difficult for drug users to access sterile equipment.[51]

India’s Narcotic Drugs and Psychotropic Substances (Amendment) Act, 2014 repealed the mandatory death sentence in cases of repeat convictions for trafficking large quantities of drugs. Courts were given discretion to impose an alternative sentence of 30 years in prison. However, in 2014, arrests for drug-related offences in India increased to the highest rate in five years. Prosecutions for drug-related offences more than doubled from 2013, and the number of convictions increased by 127%.[52]

In 2014, Bangladesh expanded its campaign against drug abuse and trafficking. Speeches and meetings were held in schools, WHO produced a series of short films, and posters, leaflets, stickers and booklets were distributed.[53]

The way forward

The continued criminalization of drugs and harsh punishments for drug-related offences make the region particularly dangerous for drug users. Harm Reduction International notes that “strengthening the response among people who use drugs in the … region will require a reorientation of laws and policies that continue to criminalise people who use drugs and hinder the implementation of evidence- and human-rights- based HIV prevention and treatment services”.[54]

As described above, several successful harm reduction and treatment programs have been provided for drug users in the region. Some of these programs have been tailored for women drug users, and have had a demonstrably positive effect on women’s lives. These programs need to be expanded and replicated across the region. However, harm reduction programs can only be fully effective if they are provided in a safe environment.

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[1] Harm Reduction International. 2012. The Global State of Harm Reduction 2012: Towards an integrated response. Harm Reduction International. At: http://www.ihra.net/files/2012/07/24/GlobalState2012_Web.pdf [Accessed April 4, 2016].

[2] International Narcotics Control Board. 2016. Report of the International Narcotics Control Board for 2015. New York: United Nations. E/INCB/2015/1. At: https://www.incb.org/incb/en/publications/annual-reports/annual-report-2015.html [Accessed April 4, 2016].

[3] Felbab-Brown, V., Trinkunas, H. and Barakat, S. March 22, 2016. ‘Breaking bad in the Middle East and North Africa: Drugs, militants, and human rights’. At: http://www.brookings.edu/blogs/markaz/posts/2016/03/22-drug-policy-middle-east-felbabbrown-trinkunas-barakat [Accessed April 15, 2016].

[4] International Narcotics Control Board. 2016.

[5] Harm Reduction International. 2012

[6] UNODC. 2016. ‘Turning the tide for women and girls who use drugs in Afghanistan’. UNODC. At: https://www.unodc.org/unodc/en/hiv-aids/turning-the-tide-for-women-and-girls-who-use-drugs-in-afghanistan.html [Accessed April 11, 2016].

[7] International Narcotics Control Board. 2016.

[8] International Narcotics Control Board. 2016.

[9] UNODC. 2016.

[10] United Nations Task Force on Transnational Organized Crime and Drug Trafficking as Threats to Security and Stability. 2014. ‘A Gender Perspective on the Impact of Drug Use, the Drug Trade, and Drug Control Regimes’. UN Women Policy Brief. UN Women. At: https://www.unodc.org/documents/ungass2016/Contributions/UN/Gender_and_Drugs_-_UN_Women_Policy_Brief.pdf [Accessed April 13, 2016].

[11] International Narcotics Control Board. 2015. Report of the International Narcotics Control Board for 2014. New York: United Nations. E/INCB/2014/1. At: https://www.incb.org/incb/en/publications/annual-reports/annual-report-2014.html [Accessed April 4, 2016].

[12] UNODC. 2016.

[13] Kensy, J., et al. 2012. ‘Drug policy and women: Addressing the negative consequences of harmful drug control’. IDPC Briefing Paper. International Drug Policy Consortium. At: http://www.grea.ch/sites/default/files/drug-policy-and-women-addressing-the-consequences-of-control.pdf [Accessed April 15, 2016].

[14] Rezaian, J. 2014. ‘Women addicted to drugs in Iran begin seeking treatment despite taboo’. The Washington Post. At: https://www.washingtonpost.com/world/middle_east/women-addicted-to-drugs-in-iran-begin-seeking-treatment-despite-taboo/2014/05/11/b11b0c59-cbb4-4f94-a028-00b56f2f4734_story.html [Accessed April 16, 2016].

[15] Harm Reduction International. 2014. The Global State of Harm Reduction 2014. Harm Reduction International. At: http://www.ihra.net/contents/1524 [Accessed May 5, 2016].

[16] Global Commission on Drug Policy. 2014. Taking Control: Pathways to Drug Policies that Work. Global Commission on Drug Policy. At: http://www.drugpolicy.org/resource/taking-control-pathways-drug-policies-work [Accessed April 16, 2016].

[17] International Narcotics Control Board. 2016.

[18] Harm Reduction International. 2012.

[19] Dolan, K., et al. 2011. The Establishment of a methadone clinic for women in Tehran. Journal of Public Health Policy. 32(2): 219-230.

[20] Harm Reduction International. 2012.

[21] International Narcotics Control Board. 2016.

[22] International Narcotics Control Board. 2016.

[23] International Narcotics Control Board. 2016.

[24] India HIV/AIDS Alliance and Social Awareness Service Organisation. 2011. In the Shadows: The Chanura Kol Baseline Study on Women who Inject Drugs in Manipur, India. New Delhi: India HIV/AIDS Alliance. At: http://www.aidsdatahub.org/sites/default/files/documents/Baseline_Study_On_Women_Who_Inject_Drugs_India.pdf [Accessed April 19, 2016].

[25] International Narcotics Control Board. 2016.

[26] International Narcotics Control Board. 2016.

[27] Harm Reduction International. 2012

[28] Harm Reduction International. 2012.

[29] Harm Reduction International. 2014.

[30] Harm Reduction International. 2012.

[31] International Narcotics Control Board. 2016.

[32] International Narcotics Control Board. 2015.

[33] Harm Reduction International. 2012.

[34] International Narcotics Control Board. 2015.

[35] International Narcotics Control Board. 2015.

[36] International Narcotics Control Board. 2016.

[37] CND Blog. ‘UNGASS Special Segment Day 3 – Interactive discussion on cross-cutting issues: drugs and human rights, youth, women, children and communities’. At: http://cndblog.org/2015/03/ungass-special-segment-day-3-interactive-discussion-on-cross-cutting-issues-drugs-and-human-rights-youth-women-children-and-communities/ [Accessed April 16, 2016].

[38] Harm Reduction International. 2012.

[39] Dearden, L. February 26, 2016. ‘Every man in Iranian village ‘executed on drugs charges’’. Independent. At: http://www.independent.co.uk/news/world/middle-east/every-man-in-iran-village-executed-on-drugs-charges-death-penalty-capital-punishment-human-rights-a6898036.html [Accessed April 21, 2016].

[40] Hosseinkhah, M. 2012. ‘The Execution of Women in Iranian Criminal Law: an Examination of the Impact of Gender on Laws Concerning Capital Punishment in the New Islamic Penal Code’. New Haven: Iran Human Rights Documentation Center. At: http://www.iranhrdc.org/english/publications/legal-commentary/1000000102-the-execution-of-women-in-iranian-criminal-law.html [Accessed April 21, 2016].

[41] Kensy, J., et al. 2012; IRIN. 2004. ‘Afghan women and opium’. At: https://www.irinnews.org/report/24804/afghanistan-afghan-women-and-opium [Accessed April 15, 2016].

[42] Kensy, J., et al. 2012.

[43] Kensy, J., et al. 2012.

[44] International Narcotics Control Board. 2016.

[45] Kensy, J., et al. 2012.

[46] Melis, M. and Nougier, M. 2010. ‘Drug policy and development: How action against illicit drugs impacts on the Millennium Development Goals.’ IDPC Briefing Paper. International Drug Policy Consortium. At: http://www.countthecosts.org/sites/default/files/Drug%20policy%20and%20development.pdf [Accessed April 15, 2016].

[47] Kensy, J., et al. 2012.

[48] International Narcotics Control Board. 2015.

[49] Melis, M. and Nougier, M. 2010.

[50] International Narcotics Control Board. 2016.

[51] Harm Reduction International. 2012.

[52] International Narcotics Control Board. 2016.

[53] International Narcotics Control Board. 2016.

[54] Harm Reduction International. 2012.