A Day With Cambodia’s Needle Exchange Team

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A Day With Cambodia’s Needle Exchange Team

By Nathan A Thompson 12/08/14
A grim but hopeful report on drug treatment in Phnom Penh, and how the Khana Harm Reduction organization is spearheading change.
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Nathan A. Thompson

CAMBODIA, Phnom Penh – Riding shotgun on the back of a rickety 110cc Honda Dream. The city blurred: yellow walls, flashes of coffee shacks, smells of breakfast soup and garbage; the horns of a thousand vehicles rose like elephant herds. 

It was 9am and the heat was already oppressive. If it wasn’t for the breeze created by the Honda’s speed, sweat would have trickled down my forehead, along my nose and dripped, soaking my trousers in brine. 

There were four of us en route to what Heng Kiry, outreach officer for Khana Harm Reduction, referred to as a “drugs hotspot” – outposts of the city’s underworld where drugs are bought and consumed. We rode two purple-painted Hondas, each bearing the Khana logo, and below it a sticker that read, “Donated by AUS Aid.”   

We carried bales of harm reduction packs—plastic sleeves containing clean needles, alcohol swabs and sterile cooking implements. They also came with a leaflet written in the fish-like swoops of the Khmer script (the Khmer ethnic group make up 90% of Cambodia’s population) but not all of Khana’s clients could read. So, to be sure, below the text were cartoons. One frame showed a young man injecting downwards with a red cross struck through it. 

We pulled in at a food shack in a low-rent area of the city. One dumpy woman presided over a straggle of plastic tables and chairs. She wore a hat that resembled an oversized baseball cap with a tea towel attached. The tea-towel appendage is used to wrap around the face and protect the skin from the sun and hot dust that blows through the city turning everything sepia-tinted, like photos of the Wild West. She stared at us over her dirty dishes, wondering whether or not we needed to be told that breakfast was over. 

The food shack was in the courtyard of what was once a low-rise office block. “This building has been abandoned for a long time,” said Kiry. “Maybe there was a dispute between the owner and the government and it couldn’t be decided who owns it.” He was referring to the confusion left by the hyper-Maoist Khmer Rouge regime that presided over Cambodia in the late 1970s. They abolished land ownership and destroyed every last property deed. It wasn’t until a decade later that official records began being kept again. In the bewilderment, the ownership of many buildings was disputed, resulting in acres of apocalyptic concrete shells. 

Inside was awash with waste. “Be careful of the needles,” said Kiry. I looked from my sandaled feet to the discarded syringes poking out from the garbage like a plethora of middle fingers. If I stepped on one, would it penetrate my sandal’s sole?

Kiry continued up a windowless staircase. Upstairs there were two large internal rooms reeking of rot and dry feces. Avoiding stepping on a fist-sized pile of human excrement, I stood next to Kiry and glanced around. Was anyone home? 

Two young men emerged and languished against a wall. They were in their early twenties, slender and brown-skinned. Sure, they’d been wasted by drug addiction, but before that they were laborers and rice-hefting farmers. Like most Cambodian working men, they retained the tough sinewy bodies usually reserved in the west for “ab-doer” infomercials. 

Kiry questioned one of the lads and relayed his brief, sorrowful answers. His name was Phana.

“I was addicted to heroin,” he said. “And then I started on [prescribed heroin substitute] methadone but carried on using heroin anyway.” Kiry explained that Phana had attended Cambodia’s only methadone clinic based at the Khmer-Soviet Friendship Hospital in Phnom Penh. Phana managed to quit his heroin and methadone addiction but soon relapsed on methamphetamine. 

“These days I just take meth,” he said. “It was so painful to withdraw from heroin and methadone – I never want to go through that again.” 

Methamphetamine is the most commonly abused drug in Cambodia where, according to Kiry, there are an estimated 13,000 addicts in a population of 15 million. “Over 80% of all [Cambodian] drug users use methamphetamines,” Oliver Lermet from United Nations Office on Drugs and Crime told Asia Life last year.“Followed by heroin, inhalants and other drugs, including cannabis,” he added.

It makes sense that Cambodia’s domestic drug market is a swamp of cheap meth and inhalants. The average wage is roughly $200pcm so there is little demand for the drugs of the privileged classes such as LSD and cocaine. Heroin is available largely because the country is a key distribution point for Myanmar-made china white.

Some of this fine white dope makes its way into the veins of local addicts, making them a high risk group for contracting HIV. By focusing on prevention methods, a partnership of NGOs like Khana and local government reduced the spread of HIV from 68 infections per day in 1995 to two in 2013. 

“We prevent the spread of HIV by giving clean needles to injecting users of heroin” said Kiry. “And we educate meth-smokers about safe injecting practices in case they begin injecting heroin or diazepam.” 

Phana stood next to Kiry, as if waiting to be dismissed by the older man. Noticing some graffiti that flowered above the trash in one of the rooms, I asked about the artist.  

“My friend did that,” said Phana. “But he’s dead now.”

We moved down the corridor. In the next room, two young addicts picked at a plastic bag containing chicken and rice porridge. One of them wore the tattered shorts and staccato ticks of a meth head, the other paused between each bite as if trying to work up the desire to eat. Hovering around them was a woman. By contrast, she brimmed with health. 

“I’m looking for my husband,” she said. “Sometimes, he’s here.” Her husband, Kiry explained, was from a wealthy family and used to be a TV news anchor. 

“He was very famous,” said Kiry. “But his addiction to meth and heroin led him to lose his job and be disowned by his parents.” The woman stood with her arms folded being surprisingly candid about her troubles.

"What will you do when you find him?" I asked.

“Beat him,” she replied.

We drove to the next location through a thronging market between plumes of steam from noodle cauldrons and calls of “ch’gnang, ch’gnang” (“delicious, delicious”).  Beyond the market, by the banks of Bassac river (one of three that intersect by Phnom Penh), we arrived at a rubble-strewn slum. Kiry led the way down a tiny, stinking alleyway. 

Halfway down the alley was a hovel lashed together from scraps of wood and stolen sheets of corrugated iron. Beyond that, between cellular shanties, was the river. The water looked okay from a distance, but the smell warned against closer examination. 

Out scrambled a man, rat-thin with the pale skin of mixed Khmer/Chinese heritage. With him tumbled a couple of toddlers. Kiry and his helpers piled dozens of harm reduction packs in front of him. He grabbed a packet, tore off the end, removed the syringe and began brushing it absentmindedly along his leg.

“This guy is a dealer,” explained Kiry. “His customers buy and inject here so that’s why we drop off a lot of needles.” The dealer didn’t want to be named or photographed. His police bribes are small as long as he maintains a low profile. 

The dealer picked up a tiny stone and held it in front of me in an open palm; it was the size of a large fly. “This is about the size of one hit,” he said. “I sell this for $5.” Remembering my days as a dope-head, I calculated that a gram probably goes for around $20. The dealer agreed. 

“But for foreigners I charge more,” he said, grinning. 

More addicts turned up to grab handfuls of harm reduction packs.  “The local community and police know about this place,” explained Kiry. “But they allow it to continue as long as the drug users are quiet and clean up all the needles.” I immediately felt better about the barefoot toddlers that scrambled about the garbage. “Once a week we come here with a bio-hazard box and collect them all,” he added. 

One of the addicts pointed to the dealer.

“He will die within months,” he said. “He injects every hour; he can’t maintain that rate of use.” The dealer stared feverishly at the needle in his hand. "Are you interested in getting clean?" I asked.

“Only when I run out of veins,” he replied. 

Now that we had finished distributing the needles, the dealer began twirling the needle between his fingers and shifting back and forth. A couple more addicts sloped against a wall staring at us. Everything became silent. A chicken dashed between our legs. 

“We should get going,” said Kiry. As we left we passed a cop drinking coffee and eating “Cha Quoi” - a fried bread snack. I guess some things are the same the world over. 

“This is where the richer addicts come,” said Kiry as we arrived at the final hotspot. “And foreigners also buy from here sometimes.”  Like their western counterparts, Khana’s wealther clients begin to use drugs at parties, develop an addiction and become destitute. 

We parked up the road from a blue-painted corrugated metal shack. There was no number and no sign outside. The street was lined with guesthouses with names like “Sunday” or “Lucky.” Halfway down the road, behind a thick wooden gate was one of the city’s more exclusive resorts. 

“We can’t approach the door because the boss doesn’t like us attracting attention to the place,” said Kiry. “It’s an illegal gambling den but people take drugs there. If people want clean equipment they will come out and meet us.” 

A young lad broke from the den’s metallic mouth and came running, carrying a black plastic bag. One of Kiry’s helpers dropped a handful of harm reduction into it. A minute later, a man emerged—tall with the pale-skin of the Cambodian upper class—he grabbed a fistful of clean needles, which he stashed in the eaves of an ornamental spirit house. 

“That’s the newscaster, you know, the guy whose wife was looking for him earlier?” said Kiry in a hushed tone. “He’s hiding the needles inside the spirit house so he can come and grab them later.” Another addict emerged, squatted behind a parked car and began cooking up a shot. 

We returned to Khana’s headquarters just before lunch. The gaudy Khmer mansion contained offices and a drop-in centre. In the main downstairs room a handful of exhausted addicts lay on cushions vaguely staring at a Korean soap opera. 

“We have 30-40 drop-in clients a day,” said Kiry. “We provide a safe space for them to relax because most work at night as scrap collectors, motorbike taxis or thieves; they have nowhere to go during the day.” 

He pointed to a chart containing clip-art style drawings – metaphors depicting the storms of drug addiction and the joy of sobriety. 

“Once a day we round everyone up for an education session about safety and treatment options,” he said.  

Inside the office the air conditioning was a reprieve from the brutal heat of the day. Typing at a computer was the centre manager, So Kimhai. He posed for a picture, 

“I must look at my most handsome,” he said and chuckled. 

“Cambodia has a Buddhist culture so we don’t use the American-style 12-step method,” he said when questioned about the U.S recovery juggernaut. “But we do provide self-help and support groups in conjunction with the methadone program.”  

“Our approach is about allowing drug users to make an informed choice about their lifestyles,” Kimhai continued. “We educate them about safety and inform them about the services available to help them quit.”

But Cambodia’s methadone program has come in for criticism due to the fact that it does not enforce a reduction program or offer safe detoxes for users who want to quit methadone. “Because our addicts live such chaotic lives it’s impossible to enforce the discipline of a methadone reduction,” said Kimhai. “So the program can only focus on trying to stabilize the addicts.” 

Treatment options for drug addicts remain thin on the ground. Apart from methadone and harm reduction NGOs like Khana, the only other option available to addicts is the notorious army boot camps where they are brutally re-educated over six weeks. “If you go to the government boot camp, you still have to pay for your food and uniform,” said Samhai. “Most of our clients can’t afford that.”  

Even though Khana plugs an important gap in Cambodia’s drug treatment provision, the organization faces an uncertain future. Their main funder, AUS Aid is pulling funding as part of a government policy to slash international aid. Khana plans to apply for support from The Global Fund to Fight AIDS, Tuberculosis and Malaria but not before they have to close their Phnom Penh drop-in center. 

It’s a shame the Australian government has enacted such a callous policy in Cambodia (adding insult to injury following their policy of dumping rejected asylum seekers on Cambodia’s shores). It means success stories will be fewer on the ground.

Successes like Keo Rithy – an ex-addict whose job at Khana team is under threat. “I first started using [methamphetamine] when I was clubbing with my friends,” he said. “The come-downs made me angry, sleepless and violent so my friends introduced me to heroin to help ease that feeling, I soon became hooked.” 

“Withdrawing from heroin and methadone was the hardest thing I ever did but I had to change. Now people who knew me as an addict, as a ghost, see that I am changed and that gives them hope. I tell them, that there is no happiness in drugs; living with family and community is where real happiness is found.” 

Nathan A Thompson is a journalist and poet. He has written for the Telegraph, the Guardian, Vice and Slate. His debut poetry collection, I Take Nothing Strong, Only Lightning is out soon on Wow Books. Follow @NathanWrites

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