International Journal of Drug Policy 10 (1999) 79–81

Editorial

Bali high? Intravenous drug use in Indonesia—when will weever learn?

While the British were active in promotingand enforcing the opium trade to China inthe 17th–19th centuries, the Dutch weregladly carrying out the same trade in Indone-sia. By the late 17th century, the Dutch wereimporting 87 tons of opium per year for theirmonopoly trade to Java and the Dutch In-dies. Again, echoing the British in China, theDutch forcibly expanded their opium trade;by 1929 this trade had become central toJava’s economy, with over a thousand opiumdens retailing 59 tons of opium per year toover 100 000 consumers (Bureau for Interna-tional Narcotics and Law Enforcement Af-fairs, 1997).

The magnitude, the brutality and the re-cency of this trade must be born in mindwhen assessing present-day Indonesia’s re-sponses to illicit drugs, as it must be whendoing the same for China, where in 1949there were an estimated 20 million opiumusers. Illicit drugs, in particular heroin andopium, are reminders for the Indonesians andChinese of a time, not very far away, whenthey were the tools of colonial oppression.

However, this historical perspective andthe sympathy it may engender should not beallowed to blind us, or the Indonesian au-

thorities, to the existence of drug use and ofthe risks for HIV transmission in Indonesia.The actual extent of the use of drugs inIndonesia, the fourth most populous nationon earth and spread over 17 000 islands with55 000 km of coastline, is unknown. How-ever, there is much anecdotal and some otherevidence of the use of marijuana, ecstasy,glue, cough mixtures, amphetamines, opiumand heroin in many parts of Indonesia, aswell as much alcoholism. Indonesia is alsorapidly becoming a major transhipmentcountry for drugs, especially amphetaminesand ecstasy, originating either in Indonesia orin the mainland of south-east Asia, and oftenusing onward routes developed for the can-nabis trade (Reid and Deany, 1997).

Of all this drug use, injecting drug use(IDU) is the most hidden phenomenon, witha reluctance on the part of the authorities torecognise its existence at all. As well, someinfluential authorities in Indonesia have haddifficulty accepting the threat of AIDS at all,protesting—as we have heard sequentiallyfrom misguided souls in Thailand, Taiwan,China, India and other countries in the re-gion—that Indonesia will be protected fromAIDS by its culture, or the lack of homosex-

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Editorial / International Journal of Drug Policy 10 (1999) 79–8180

uality or of injecting drug use, or because ofracial characteristics. A not uncommon per-ception as well is that harm reduction ap-proaches to the prevention of HIV amongIDUs are western creations not politically orculturally appropriate in Asia. That this isuntrue is exemplified by the range of suchprograms now in existence (Crofts et al.,1998).

The paper by Setiawan et al. (1998) in thisissue of the Journal demonstrates that IDUcertainly exists in Indonesia, that it is a veryunderground and hidden activity, largely as aresult of the attitudes and behaviours of theauthorities, and that there is enormous po-tential risk for HIV transmission. Thedifficulty of carrying out research in this areaforeshadows the immense difficulties facingIndonesia in preventing epidemics of HIVinfection among these hidden IDUs.

Indonesia has a long sea border, and is aregular stopover for fishing boats from theThai fleet, with fishermen using the servicesof sex workers in many towns and villages.This fleet is also deeply involved in the drugtrade, bringing heroin and amphetaminesfrom Thailand, Burma and other parts of theGolden Triangle region. It is almost certainlyalso bringing HIV (though this has not beendemonstrated), an impression which has ledto incidents in which Indonesian villagersblame and attack the fishermen (BangkokPost, 1997). Indonesia, as well, is goingthrough a most difficult time of political andeconomic restructuring, which is leavingmany millions unemployed and well belowthe poverty line.

There are similarities here with what hasbeen happening in Eastern Europe and thenewly independent states such as Ukraineand Moldova (Burrows et al., 1998). In acontext of chaotic social and economic up-heaval and dislocation, drug use seems to beflourishing, and IDU seems to be becoming

more common though remaining extremelyhidden. HIV is present, and largely ignored.All the preconditions seem to exist for theexplosive spread of HIV among these veryhidden IDUs in Indonesia, and from them totheir sexual partners and onwards, and totheir children—a starting point for majornational epidemics of HIV and of AIDS.

As a global community we have failed tolearn the obvious lessons from a whole seriesof examples, from New York, Edinburgh andMilan, to Bangkok, Burma, Manipur andRuili County, to Eastern Europe—that ifaction is taken early then these epidemics canbe stopped with relatively few resources, butif it is delayed, then control becomes nighimpossible (Wodak and des Jarlais, 1993).These lessons have not even been properlylearned by the multinational agencies andfunders. How does one promote a responsein countries at risk, such as Indonesia, beforethe epidemic of HIV infection among IDUstakes off—especially in the midst of multipleother, often more pressing, problems, includ-ing other health and medical priorities as wellas all the social and economic problems? Forthese and other reasons, most countries inAsia have given little emphasis to the HIVepidemic among IDUs in their nationalAIDS programs. How does one raise thepriority assigned for HIV prevention amongIDUs?

And then, even in a country where theproblem is clearly recognised, identified andaccorded priority how does one get the fund-ing agencies to accord a similar priority?Vietnam is, at the moment, facing recurringexplosive outbreaks of HIV among IDUs,province by province, the start of the na-tional epidemic (Lindan et al., 1997). TheNational AIDS Committee of Vietnam hasaccorded the highest priority to stopping thisspread, and has adopted a pragmatic harmreduction approach—almost alone among

Editorial / International Journal of Drug Policy 10 (1999) 79–81 81

countries in Asia, Vietnam has been pre-pared to learn from others’ experience. How-ever, raising funding from the globalcommunity to support this approach hasbeen extremely difficult, and the opportuni-ties for significantly ameliorating the epi-demic and its effects are rapidly slippingaway.

Injecting drug users are not the flavour ofthe month with any of the major fundingagencies, nor of any of the UN agenciesexcept the UN Joint Programme on AIDS(UNAIDS), and this last is a mixed bless-ing—the promise of much, the delivery oflittle. The suggestion that HIV epidemicsamong IDUs and sex workers move indepen-dently, generalising from the experience inThailand, is both demonstrably not true inmany Asian countries and enormously dam-aging to attempts to generate a response toepidemics of HIV among IDUs (Francois-Xavier Bagnoud Center for Health and Hu-man Rights, 1997). Countries such asMalaysia can justify their almost total lackof action in the face of a raging HIV epi-demic among IDUs by maintaining that theHIV epidemic will be contained among theIDUs, who are of course of no value tosociety.

Indonesia presents us with another oppor-tunity, another challenge. There may not bean epidemic of HIV among Indonesian IDUsin the future—the assessment of the riskpresented above, based on inadequate data,may be wide of the mark, though Setiawanet al.s paper suggests otherwise—but howmany more times will we see totally pre-ventable HIV epidemics occur because wewere not prepared to learn from history, andact when action may help?

Nick CroftsThe Centre for Harm Reduction,

The Macfarlane Burnet Centre forMedical Research,

P.O. Box 254, Fairfield, Victoria 3078,Australia

Tel.: +6-13-9282-2169;fax: +61-3-9482-3123

E-mail: crofts@burnet.edu.au

References

Thai fishermen blamed for infecting Indonesians.Bangkok Post, 23 June 1997 (ftp://ftp.inet.co.th/pub/sea-aids/news/news39.txt).

Bureau for International Narcotics and Law Enforce-ment Affairs. International Narcotic Strategy Re-port, 1996. Indonesia, Washington DC: UnitedStates Department of State, March 1997.

Burrows D, Rhodes T, Trautmann F, Bijl M, StimsonG, Sarankov Y, Ball A, Fitch C. Responding toHIV infection associated with drug injecting in East-ern Europe. Drug Alcohol Rev 1998 (in press).

Crofts N, Costigan G, Narayanan P, et al. HarmReduction in Asia: a successful response to hiddenepidemics. AIDS 1998;12:S109–15.

Monitoring the AIDS Pandemic. The status and trendsof HIV/AIDS/STD epidemics in Asia and thePacific. Boston: Francois-Xavier Bagnoud Centerfor Health and Human Rights, 1997, p. 7.

Lindan CP, Lieu TX, Giang LT, et al. Rising HIVinfection rates in Ho Chi Minh City herald emergingAIDS epidemic in Vietnam. AIDS 1997;11(Suppl1):S5–S13.

Reid G, Deany P. The Hidden Epidemic: a situationassessment of drug use in south east and east Asia inthe context of HIV vulnerability. Chiang Mai: AsianHarm Reduction Network, 1997.

Setiawan IM, Patten J, Triadi A, Yulianto S, AdnyanaIPGT, Arif M. Report on intravenous drug use inBali: results of an interview survey. Int J DrugPolicy 1998;10:109–116.

Wodak A, des Jarlais DC. Strategies for the preventionof HIV infection among and from injecting drugusers. Bull Narcotics 1993;45:47–60.

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