evidence informed response to illicit drugs in indonesia
Correspondence
After the Rio +20 conference in
2012, in Brazil, a series of proposed
Sustainable Development Goals (SDGs)
were developed.1 This broad vision for
the future incorporates a pledge to
reduce inequality within and among
countries; ensure healthy lives and
promote wellbeing for all at all ages;
and promote peaceful and inclusive
societies for sustainable development,
in addition to other goals.1 As with the
Millennium Development Goals that
they supersede, the SDGs will redefine
the political and financial commitment
to global development during the next
15 years.
In their letter to The Lancet,
Ilona Kickbusch and colleagues
(March 21, p 1069),2 called for an
additional SDG (SDG18) that would
recognise global health security as an
important stand-alone component of
the post-2015 development agenda.
The ongoing Ebola virus outbreak in the
west African countries of Sierra Leone,
Guinea, and Liberia, has reignited global
health security debates. Kickbusch
and colleagues2 draw on this health
emergency to propose their additional
goal, “to reduce the vulnerability of
people around the world to new, acute,
or rapidly spreading risks to health,
particularly those threatening to cross
international borders”.
Although the present Ebola virus
outbreak reveals a clear breakdown of
disease surveillance and a subsequent
sluggish humanitarian response, health
advocates should guard against the
endorsement of increasingly robust
global health security measures as a
solution to such difficulties. WHO’s
widely circulated definition of global
health security—the “activities
required...to minimize vulnerability to
acute public health events”—underplays
what remains a controversial concept.3
As Simon Rushton argues,4 a framework
for global health security should be
assessed against empirical evidence,
and not solely on the basis of theoretical
www.thelancet.com Vol 385 June 6, 2015
composition and carefully crafted
definitions, to determine whether the
concept is a viable model for health
development.
The securitisation (ie, depiction
of health as a threat to a nation’s
security) of health has distilled health
issues of international concern largely
down to highly virulent infectious
diseases and bioterrorist threats. 3
For this reason, the agenda for
global health security has a skewed
priority setting in health, creating a
disconnect between perceived threats
to health and the leading causes of
morbidity and mortality worldwide.3
For example, the predicted spread of
malaria in countries affected by the
Ebola virus is further evidence of the
need to avoid a single disease-specific
approach in times of crisis.5
Criticisms have been raised about the
way in which a predominantly North
American and European interpretation
of risk and susceptibilty has been used
to define health security discourse
internationally. With substantial
financial and political power, many
high-income countries are able to
project their own foreign policy
priorities and state security interests
during the design and implementation
of large-scale global health and
humanitarian programmes.3,4 UNDP
made no effort to underplay the way
in which the infection of people in
the USA and Europe with the Ebola
virus coincided with a commitment
from the international community
to respond to this outbreak, many
months after the first case was
registered.6 This delay makes a mockery
of the shared susceptibility and
responsibility discourse championed
by advocates of global health security.
With only a few months remaining
before member states of the UN
convene in New York to finalise the
SDGs, health advocates should question
the resurgence of global health security
and seek to disentangle the perceived
vested interests of a minority from the
overwhelming needs of the majority.
I declare no competing interests.
James Smith
Amanda Hall/Robert Harding World Imagery/Corbis
Global health security:
a flawed SDG framework
james.dominic.smith@gmail.com
North East Thames Foundation School, London
E1 2DR, UK
1
2
3
4
5
6
UN. Open working group proposal for
sustainable development goals (A/68/970).
New York; United Nations, 2014.
Kickbusch I, Orbinski J, Winkler T, Schnabel A.
We need a sustainable development goal 18
on global health security. Lancet 2015;
385: 1069.
Stevenson MA, Moran M. Health security and
the distortion of the global health agenda.
In: Rushton S, Youde J, eds. Routledge
handbook of global health security. Abingdon;
Routledge, 2014.
Rushton S. Global health security: security for
whom? Security from what? Polit Stud 2011;
59: 779–96.
Walker PG, White MT, Griffin JT, Reynolds A,
Ferguson NM, Ghani AC. Malaria morbidity
and mortality in Ebola-affected countries
caused by decreased health-care capacity, and
the potential effect of mitigation strategies:
a modelling analysis. Lancet Infect Dis 2015;
published online April 23. DOI:10.1016/
S1473-3099(15)70124-6.
UNDP. Assessing the socio-economic impacts of
Ebola virus disease in Guinea, Liberia, and Sierra
Leone: the road to recovery. New York; United
Nations Development Programme, 2014.
For more about the Rio +20
conference see http://www.
uncsd2012.org/about.html
Evidence-informed
response to illicit drugs
in Indonesia
To address the serious harm caused by
drugs to individuals and the community
is an important public health priority
and one that all countries, including
Indonesia, must tackle.
The Indonesian Government,
led by President Joko Widodo, has
heralded its commitment to evidencebased policy making. The public
health community welcomes this
commitment; however, as researchers,
scientists, and practitioners, we have
grave concerns that the government is
missing an opportunity to implement
an effective response to illicit drugs
informed by evidence.
A close examination of the nature and
extent of drug use in Indonesia reveals
substantial gaps in knowledge and a
scarcity of evidence to support forced
rehabilitation and the punitive, lawenforcement-led approach favoured by
the government.
For WHO’s definition of global
public health security in the
21st century see http://www.
who.int/whr/2007/overview/en/
index.html
Submissions should be
made via our electronic
submission system at
http://ees.elsevier.com/
thelancet/
2249
Correspondence
See appendix for a full list of
signatories
2250
Opioid overdose and infectious
diseases, including HIV transmitted
through unsafe injecting practices,
are the primary causes of
drug-related deaths worldwide. 1
In the past 10 years, Indonesia has
taken positive steps forward by
introducing strategies such as opioid
substitution therapy, needle and
syringe programmes, and increased
access to HIV treatment. Substantial
evidence2 supports the effectiveness
of these interventions in reducing
fatal overdose and HIV transmission,
morbidity, and mortality. However,
these interventions have yet to be
implemented to scale in Indonesia,
and this delay is preventing the
realisation of their potential benefit.
Meanwhile, there is evidence that
criminalisation of people who use
drugs and punitive law-enforcement
approaches have failed to reduce the
prevalence of drug use and are fuelling
the HIV epidemic. 3 Compulsory
detention and rehabilitation of drug
users has been shown to be ineffective
in sustaining reductions in drug use.4
The Indonesian Government has
frequently cited National Narcotics
Board studies from 20085 and 2011,6
which estimate drug-use prevalence
to be 2·6% in the general population
(equivalent to 4·5 million people) and
as many as 50 deaths per day from
drug-related causes. We have serious
concerns about the validity of these
estimates for the following reasons:
the details and methods of these
studies are not publicly accessible;
from information that is available,
the recruitment methods appear to
have been inappropriate, resulting
in an unrepresentative sample and
results that are not generalisable;
differentiation between different
types of drugs and frequency and
patterns of their use were inadequate
to identify problematic drug use;
definitions of addiction were
inconsistent with accepted criteria for
drug dependence; and the unorthodox
method used to indirectly estimate
drug-related mortality is unreliable.
We call on the Indonesian
Government to scale back punitive
strategies that are ineffective and
counterproductive and instead
expand evidence-based interventions,
such as opioid substitution therapy,
needle and syringe programmes, HIV
treatment, and care for people who use
drugs; invest in the collection of better
quality data on the scale and nature of
drug use in Indonesia, without which
an effective and appropriately targeted
response cannot be developed; and
form a national committee on drug
use, comprising the National Narcotics
Board, Ministry of Health, Ministry
of Social Affairs, Ministry of Law and
Human Rights, service providers, and
community representatives, to review
drug-related data, set priorities,
recommend evidence-informed
actions, and monitor progress. We
support a transparent, peer-reviewed
process for collecting data on drug-use
indicators, and a commensurate
evidence-based policy response.
We declare no competing interests.
*Irwanto, Dewa N Wirawan,
Ignatius Praptoraharjo,
Sulistyowati Irianto, Siti Musdah Mulia,
on behalf of 11 signatories
Irwanto_i@yahoo.com
HIV/AIDS Research Centre, Atma Jaya Catholic
University of Indonesia, Jakarta, Indonesia (I); Public
Health Postgraduate Program, Udayana University,
Denpasar, Indonesia (DNW); Center for Health
Policy and Management, Faculty of Medicine,
Gadjah Mada University, Yogyakarta, Indonesia (IP);
Faculty of Law, Universitas Indonesia, Jakarta,
Indonesia (SI); and Indonesian Conference on
Religion for Peace, Jakarta, Indonesia (SMM)
1
2
3
4
Degenhardt L, Whiteford HA, Ferrari AJ, et al.
Global burden of disease attributable to illicit
drug use and dependence: findings from the
Global Burden of Disease Study 2010. Lancet
2013; 382: 1564–74.
Tilson H, Aramrattana A, Bozzette S.
Preventing HIV infection among injecting drug
users in high-risk countries: an assessment of
the evidence. Washington, DC: Institute of
Medicine, 2007.
Reuter P. Ten years after the United Nations
General Assembly Special Session (UNGASS):
assessing drug problems, policies and reform
proposals. Addiction 2009; 104: 510–17.
WHO Regional Office for the Western Pacific.
Assessment of compulsory treatment of
people who use drugs in Cambodia, China,
Malaysia and Viet Nam: an application of
selected human rights principles. Manila: WHO
Regional Office for the Western Pacific, 2009.
5
6
Badan Narkotika Nasional bekerjasama
dengan Pusat Penelitian Kesehatan
Universitas Indonesia. Laporan Survei
Penyalahgunaan Narkoba di Indonesia: Studi
Kerugian Ekonomi dan Sosial akibat Narkoba,
tahun 2008. Jakarta: Badan Narkotika
Nasional, 2008.
Badan Narkotika Nasional bekerjasama
dengan Pusat Penelitian Kesehatan Universitas
Indonesia. Ringkasan Eksekutif Survei
Penyalahgunaan Narkoba di Indonesia: Studi
Kerugian Ekonomi dan Sosial akibat Narkoba,
tahun 2011. Jakarta: Badan Narkotika
Nasional, 2011.
ISAT: end of the debate
on coiling versus
clipping?
In the International Subarachnoid
Aneurysm Trial (ISAT) of neurosurgical
clipping versus endovascular coiling
by Andrew Molyneux and colleagues,1
the study design was optimal for a
short-term follow-up. The primary
objective of this study was to establish
outcomes at 1 year after surgery,
and the secondary objective was to
assess differences in the rebleeding
rate. Since surgery has a high success
rate in eliminating the lifelong risk of
rebleeding,1 the establishment of new
treatments should be based on at least
a similar success rate or superior safety.
The 10 year ISAT results (Feb 21,
p 691)2 suggest that endovascular
coiling is perhaps safer than neurosurgical clipping in treating ruptured
intra cranial aneurysms (table).
However, with respect to the secondary
objective, overall rebleeding rate was
higher after endovascular treatment
(table). The estimated 1 year rerupture
rate of 2·6–2·8%1 of target intracranial
aneurysms corresponds to the
reported natural course of 7–12 mm
unruptured intracranial aneurysms
in the anterior circulation and is
more than 20 times higher than the
reported rupture rate of small (
After the Rio +20 conference in
2012, in Brazil, a series of proposed
Sustainable Development Goals (SDGs)
were developed.1 This broad vision for
the future incorporates a pledge to
reduce inequality within and among
countries; ensure healthy lives and
promote wellbeing for all at all ages;
and promote peaceful and inclusive
societies for sustainable development,
in addition to other goals.1 As with the
Millennium Development Goals that
they supersede, the SDGs will redefine
the political and financial commitment
to global development during the next
15 years.
In their letter to The Lancet,
Ilona Kickbusch and colleagues
(March 21, p 1069),2 called for an
additional SDG (SDG18) that would
recognise global health security as an
important stand-alone component of
the post-2015 development agenda.
The ongoing Ebola virus outbreak in the
west African countries of Sierra Leone,
Guinea, and Liberia, has reignited global
health security debates. Kickbusch
and colleagues2 draw on this health
emergency to propose their additional
goal, “to reduce the vulnerability of
people around the world to new, acute,
or rapidly spreading risks to health,
particularly those threatening to cross
international borders”.
Although the present Ebola virus
outbreak reveals a clear breakdown of
disease surveillance and a subsequent
sluggish humanitarian response, health
advocates should guard against the
endorsement of increasingly robust
global health security measures as a
solution to such difficulties. WHO’s
widely circulated definition of global
health security—the “activities
required...to minimize vulnerability to
acute public health events”—underplays
what remains a controversial concept.3
As Simon Rushton argues,4 a framework
for global health security should be
assessed against empirical evidence,
and not solely on the basis of theoretical
www.thelancet.com Vol 385 June 6, 2015
composition and carefully crafted
definitions, to determine whether the
concept is a viable model for health
development.
The securitisation (ie, depiction
of health as a threat to a nation’s
security) of health has distilled health
issues of international concern largely
down to highly virulent infectious
diseases and bioterrorist threats. 3
For this reason, the agenda for
global health security has a skewed
priority setting in health, creating a
disconnect between perceived threats
to health and the leading causes of
morbidity and mortality worldwide.3
For example, the predicted spread of
malaria in countries affected by the
Ebola virus is further evidence of the
need to avoid a single disease-specific
approach in times of crisis.5
Criticisms have been raised about the
way in which a predominantly North
American and European interpretation
of risk and susceptibilty has been used
to define health security discourse
internationally. With substantial
financial and political power, many
high-income countries are able to
project their own foreign policy
priorities and state security interests
during the design and implementation
of large-scale global health and
humanitarian programmes.3,4 UNDP
made no effort to underplay the way
in which the infection of people in
the USA and Europe with the Ebola
virus coincided with a commitment
from the international community
to respond to this outbreak, many
months after the first case was
registered.6 This delay makes a mockery
of the shared susceptibility and
responsibility discourse championed
by advocates of global health security.
With only a few months remaining
before member states of the UN
convene in New York to finalise the
SDGs, health advocates should question
the resurgence of global health security
and seek to disentangle the perceived
vested interests of a minority from the
overwhelming needs of the majority.
I declare no competing interests.
James Smith
Amanda Hall/Robert Harding World Imagery/Corbis
Global health security:
a flawed SDG framework
james.dominic.smith@gmail.com
North East Thames Foundation School, London
E1 2DR, UK
1
2
3
4
5
6
UN. Open working group proposal for
sustainable development goals (A/68/970).
New York; United Nations, 2014.
Kickbusch I, Orbinski J, Winkler T, Schnabel A.
We need a sustainable development goal 18
on global health security. Lancet 2015;
385: 1069.
Stevenson MA, Moran M. Health security and
the distortion of the global health agenda.
In: Rushton S, Youde J, eds. Routledge
handbook of global health security. Abingdon;
Routledge, 2014.
Rushton S. Global health security: security for
whom? Security from what? Polit Stud 2011;
59: 779–96.
Walker PG, White MT, Griffin JT, Reynolds A,
Ferguson NM, Ghani AC. Malaria morbidity
and mortality in Ebola-affected countries
caused by decreased health-care capacity, and
the potential effect of mitigation strategies:
a modelling analysis. Lancet Infect Dis 2015;
published online April 23. DOI:10.1016/
S1473-3099(15)70124-6.
UNDP. Assessing the socio-economic impacts of
Ebola virus disease in Guinea, Liberia, and Sierra
Leone: the road to recovery. New York; United
Nations Development Programme, 2014.
For more about the Rio +20
conference see http://www.
uncsd2012.org/about.html
Evidence-informed
response to illicit drugs
in Indonesia
To address the serious harm caused by
drugs to individuals and the community
is an important public health priority
and one that all countries, including
Indonesia, must tackle.
The Indonesian Government,
led by President Joko Widodo, has
heralded its commitment to evidencebased policy making. The public
health community welcomes this
commitment; however, as researchers,
scientists, and practitioners, we have
grave concerns that the government is
missing an opportunity to implement
an effective response to illicit drugs
informed by evidence.
A close examination of the nature and
extent of drug use in Indonesia reveals
substantial gaps in knowledge and a
scarcity of evidence to support forced
rehabilitation and the punitive, lawenforcement-led approach favoured by
the government.
For WHO’s definition of global
public health security in the
21st century see http://www.
who.int/whr/2007/overview/en/
index.html
Submissions should be
made via our electronic
submission system at
http://ees.elsevier.com/
thelancet/
2249
Correspondence
See appendix for a full list of
signatories
2250
Opioid overdose and infectious
diseases, including HIV transmitted
through unsafe injecting practices,
are the primary causes of
drug-related deaths worldwide. 1
In the past 10 years, Indonesia has
taken positive steps forward by
introducing strategies such as opioid
substitution therapy, needle and
syringe programmes, and increased
access to HIV treatment. Substantial
evidence2 supports the effectiveness
of these interventions in reducing
fatal overdose and HIV transmission,
morbidity, and mortality. However,
these interventions have yet to be
implemented to scale in Indonesia,
and this delay is preventing the
realisation of their potential benefit.
Meanwhile, there is evidence that
criminalisation of people who use
drugs and punitive law-enforcement
approaches have failed to reduce the
prevalence of drug use and are fuelling
the HIV epidemic. 3 Compulsory
detention and rehabilitation of drug
users has been shown to be ineffective
in sustaining reductions in drug use.4
The Indonesian Government has
frequently cited National Narcotics
Board studies from 20085 and 2011,6
which estimate drug-use prevalence
to be 2·6% in the general population
(equivalent to 4·5 million people) and
as many as 50 deaths per day from
drug-related causes. We have serious
concerns about the validity of these
estimates for the following reasons:
the details and methods of these
studies are not publicly accessible;
from information that is available,
the recruitment methods appear to
have been inappropriate, resulting
in an unrepresentative sample and
results that are not generalisable;
differentiation between different
types of drugs and frequency and
patterns of their use were inadequate
to identify problematic drug use;
definitions of addiction were
inconsistent with accepted criteria for
drug dependence; and the unorthodox
method used to indirectly estimate
drug-related mortality is unreliable.
We call on the Indonesian
Government to scale back punitive
strategies that are ineffective and
counterproductive and instead
expand evidence-based interventions,
such as opioid substitution therapy,
needle and syringe programmes, HIV
treatment, and care for people who use
drugs; invest in the collection of better
quality data on the scale and nature of
drug use in Indonesia, without which
an effective and appropriately targeted
response cannot be developed; and
form a national committee on drug
use, comprising the National Narcotics
Board, Ministry of Health, Ministry
of Social Affairs, Ministry of Law and
Human Rights, service providers, and
community representatives, to review
drug-related data, set priorities,
recommend evidence-informed
actions, and monitor progress. We
support a transparent, peer-reviewed
process for collecting data on drug-use
indicators, and a commensurate
evidence-based policy response.
We declare no competing interests.
*Irwanto, Dewa N Wirawan,
Ignatius Praptoraharjo,
Sulistyowati Irianto, Siti Musdah Mulia,
on behalf of 11 signatories
Irwanto_i@yahoo.com
HIV/AIDS Research Centre, Atma Jaya Catholic
University of Indonesia, Jakarta, Indonesia (I); Public
Health Postgraduate Program, Udayana University,
Denpasar, Indonesia (DNW); Center for Health
Policy and Management, Faculty of Medicine,
Gadjah Mada University, Yogyakarta, Indonesia (IP);
Faculty of Law, Universitas Indonesia, Jakarta,
Indonesia (SI); and Indonesian Conference on
Religion for Peace, Jakarta, Indonesia (SMM)
1
2
3
4
Degenhardt L, Whiteford HA, Ferrari AJ, et al.
Global burden of disease attributable to illicit
drug use and dependence: findings from the
Global Burden of Disease Study 2010. Lancet
2013; 382: 1564–74.
Tilson H, Aramrattana A, Bozzette S.
Preventing HIV infection among injecting drug
users in high-risk countries: an assessment of
the evidence. Washington, DC: Institute of
Medicine, 2007.
Reuter P. Ten years after the United Nations
General Assembly Special Session (UNGASS):
assessing drug problems, policies and reform
proposals. Addiction 2009; 104: 510–17.
WHO Regional Office for the Western Pacific.
Assessment of compulsory treatment of
people who use drugs in Cambodia, China,
Malaysia and Viet Nam: an application of
selected human rights principles. Manila: WHO
Regional Office for the Western Pacific, 2009.
5
6
Badan Narkotika Nasional bekerjasama
dengan Pusat Penelitian Kesehatan
Universitas Indonesia. Laporan Survei
Penyalahgunaan Narkoba di Indonesia: Studi
Kerugian Ekonomi dan Sosial akibat Narkoba,
tahun 2008. Jakarta: Badan Narkotika
Nasional, 2008.
Badan Narkotika Nasional bekerjasama
dengan Pusat Penelitian Kesehatan Universitas
Indonesia. Ringkasan Eksekutif Survei
Penyalahgunaan Narkoba di Indonesia: Studi
Kerugian Ekonomi dan Sosial akibat Narkoba,
tahun 2011. Jakarta: Badan Narkotika
Nasional, 2011.
ISAT: end of the debate
on coiling versus
clipping?
In the International Subarachnoid
Aneurysm Trial (ISAT) of neurosurgical
clipping versus endovascular coiling
by Andrew Molyneux and colleagues,1
the study design was optimal for a
short-term follow-up. The primary
objective of this study was to establish
outcomes at 1 year after surgery,
and the secondary objective was to
assess differences in the rebleeding
rate. Since surgery has a high success
rate in eliminating the lifelong risk of
rebleeding,1 the establishment of new
treatments should be based on at least
a similar success rate or superior safety.
The 10 year ISAT results (Feb 21,
p 691)2 suggest that endovascular
coiling is perhaps safer than neurosurgical clipping in treating ruptured
intra cranial aneurysms (table).
However, with respect to the secondary
objective, overall rebleeding rate was
higher after endovascular treatment
(table). The estimated 1 year rerupture
rate of 2·6–2·8%1 of target intracranial
aneurysms corresponds to the
reported natural course of 7–12 mm
unruptured intracranial aneurysms
in the anterior circulation and is
more than 20 times higher than the
reported rupture rate of small (