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Navigating a Rotten Compromise

Last week, the Open Society Institute hosted a meeting in Washington to bring together U.S. government officials and aid organizations providing HIV services in Asia. We wanted to call attention to the fact that U.S. funds (particularly through the U.S. President’s Emergency Plan for AIDS Relief) are being used to support work in and around detention centers where people who use drugs are routinely abused. There are more than 400,000 people in these places—ostensibly compulsory drug rehabilitation centers, though, as I have blogged previously, they are operated by the police and the detainees are held there without trial, appeal, or medical evaluation.

In China, Vietnam, and Cambodia, detainees in these centers report being beaten by guards, sexually abused, and starved. In China and Vietnam, they are forced to work without pay, often in the service of private companies that contract for slave labor with the centers, with severe beatings if you don’t meet your work quota.  Even if you enter voluntarily you are beaten within an inch of your life if you try to escape before the end of your term, and terms have been progressively extended.  Now, China interns you for up to two years for a positive urine test, and in Vietnam it can be up to four.

Every center in Vietnam has a “punishment room”—by law.  Infractions like smoking a cigarette or drinking tea may land you in this room for weeks at a time. In here, you may be forced to hang for hours by one or both arms, made to kneel for hours on sharp objects, forced to squat in water in a room that is too small to stand up in, or just left alone for weeks  in a one meter by one meter room that is too small to lie down in.

Funders and those who implement their programs are left with a very real ethical and programmatic conundrum. If people are starving in a concentration camp, do you go in and serve them food? How about medicines for those with HIV? If you do decide to go in, how do you talk and think about it to ensure that you’re not just working to perpetuate a system that is illegal, immoral, and in fact only impedes the public health goals you are supposed to be supporting? As one of the ethicists at the meeting described, you want to avoid what philosopher Avishai Margolit calls the “rotten compromise”—working to reach common understanding with a system so fundamentally organized around humiliation or degradation that a collaboration is ethically unworkable.

The U.S. government-funded implementers working in or around the organizations have been relatively loose with their thinking and descriptions—one, in China, says it works “in partnership” with the public security bureau. Another, in Cambodia, announced that it looked forward to working with one of the centers to make it a “model of excellence.” This was a place that tasered and starved detainees. After criticism, the plan was shelved, but there is still no clear policy about when or how to engage. HIV experts have not gotten bogged down by the forced labor or human rights issues. They see their job as getting HIV services to people in need, and meeting their targets. In Vietnam and China, where the HIV epidemics are driven by injecting drug use, these centers are where the HIV is.

At our meeting, representatives from international humanitarian organizations talked about how they grapple with work in prisons, where people are also often treated badly, by making sure that they have unlimited access to all patients/prisoners, reporting abuses to authorities, and being ready to leave if they don’t feel like they’re making substantive change. It was clear that there are more questions than answers when it comes to current work in Cambodia, China, and Vietnam. It was also clear that most agencies working in these centers or on laws related to them, had not been given guidance on how to deal with the hard questions.  One HIV program implementer said there were no reported abuses in the centers they worked in—but then acknowledged that they had never asked.

The meeting was a great start, and we hope the U.S. Global AIDS Coordinator will issue formal guidance on the centers and call for their closure. Since the U.S. government is a many-splendored thing, even understanding who needs to be at the table to develop a guidance note is complicated: the drug control branch of the state department, known colloquially as “drugs and thugs” and more formally as the Bureau of International Narcotics and Law Enforcement Affairs, funds training in these centers.  The question of forced labor may be of interest as the U.S. engages in trade negotiations with Vietnam. We also met with Congressional and National Security Council staff, who we hope will investigate the question of how much the U.S. government is spending on work in or around these kind of centers and how abuses could be curtailed.

For closed and semi-closed societies, these kinds of ethical measures of benefit vs. harm are not restricted to detention centers.  Urging NGOs to engage with marginalized populations in facilities or countries where the moral dilemmas are stark means that all of us—donors, health implementers, and advocates—need to keep asking ourselves the hard ethical  questions as  we navigate the “rotten compromise.”

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