Background
In many countries, illicit drug use remains a significant problem, and the dominant response continues to be the enforcement of drug laws that criminalize illicit drug use and trafficking [
1]. However, a burgeoning body of international literature suggests that the overreliance on law enforcement-based approaches produces unintended negative consequences, including the perpetuation of human immunodeficiency virus (HIV) epidemics among people who inject drugs (IDU), as these approaches have been associated with an unwillingness to carry sterile syringes and risky injection behaviour among this population [
2‐
4]. The reliance on drug law enforcement continues despite international guidelines issued by agencies of the United Nations that recommend a public health approach to problematic drug use (e.g., harm reduction services such as sterile syringe programs) [
5].
Thailand has experienced longstanding epidemics of illicit drug use and HIV among IDU, with an estimated 5% of the population using illicit drugs in 2007 and an estimated 30–50% of IDU living with HIV/AIDS over two decades [
6,
7]. Although Thailand enacted a new law that reclassified people who use drugs as “patients” not “criminals” in 2002, the criminal laws governing drug use remain in effect, and the Thai government has continued to support intensive police crackdowns, as well as compulsory detention and incarceration of people who use drugs [
8]. Between 2008 and 2011, Thai drug policies were revised several times, and the number of people who use drugs targeted to undergo mandatory rehabilitation programs has increased from 60,000 in 2008 to 400,000 in 2011 [
9‐
12]. It has been reported that during the Thai “war on drugs” in 2003, the government’s strong emphasis on drug suppression efforts led the Thai police to commit various forms of violence, including over 2,800 extrajudicial killings of alleged drug dealers and users [
13,
14]. Although the Thai government promised that the police would not breach due process again, recent reports suggest that police misconduct has continued during subsequent crackdowns. For example, a 2008 study showed that almost half of a sample of IDU in Bangkok reported having drugs planted on them by police [
15]. Further, other reports documented police misconduct and fatal shootings of suspects during drug suppression operations in 2012 [
16,
17].
Despite ongoing concern regarding the renewed and intensified crackdowns on drug use in Thailand, few studies have endeavored to identify the extent and impact of specific forms of police violence among IDU. Although many detailed narratives on police violence were documented during the “war on drugs” in 2003 [
13], few studies have been undertaken in the post-2003 period [
15,
18]. As well, while international literature indicates that aggressive drug law enforcement practices increase vulnerability to HIV infection and other harms among IDU [
4,
19‐
21], these studies have tended to focus on the aggregate impact of police crackdowns of relatively short duration, and the impact of specific forms of police misconduct has seldom been quantified. Moreover, most of the previous academic research in this field has been conducted in Western countries, not in Southeast Asia where the legal and social environments surrounding illicit drug use are distinct from those in Western settings [
22]. Therefore, we sought to identify the prevalence and correlates of experiencing police beating among a community-recruited sample of IDU in Bangkok, Thailand.
Results
Among 644 unique IDU recruited between June 2009 and October 2011, 639 individuals (307 individuals in 2009 and 332 individuals in 2011) had complete data and were eligible for inclusion in the present analyses. The median age of eligible participants was 37 years (interquartile range: 33–47 years), and 153 (23.9%) were female. In total, 240 participants (37.6%) reported having ever been beaten by police. The unadjusted prevalence of experiencing police beating increased from 31.3% in 2009 to 43.4% in 2011 (p = 0.002). Twenty-one individuals (3.3%) reported having been beaten by police in the past six months (6 individuals [2.0%] in 2009 and 15 individuals [4.5%] in 2011; p = 0.082).
The results of bivariate analyses are shown in Table
1. Reports of police beatings were significantly and positively associated with male gender (prevalence ratio [PR]: 5.50; 95% confidence interval [CI]: 3.24–9.33); a history of heroin injection (PR: 2.45; 95% CI: 1.45–4.15), midazolam injection (PR: 1.52; 95% CI: 1.10–2.10), and crystal methamphetamine injection (PR: 1.47; 95% CI: 1.17–1.84); a history of syringe sharing (PR: 1.93; 95% CI: 1.52–2.45); a history of incarceration (PR: 3.00; 95% CI: 1.98–4.56); a history of compulsory drug detention (PR: 1.33; 95% CI: 1.06–1.66); a history of methadone treatment enrolment (PR: 1.74; 95% CI: 1.30–2.33); reporting barriers to accessing healthcare (PR: 1.55; 95% CI: 1.25–1.93); HIV seropositivity (PR: 1.35; 95% CI: 1.08–1.67); a history of non-fatal overdose (PR: 1.60; 95% CI: 1.32–1.95); and study enrolment in 2011 (PR: 1.39; 95% CI: 1.13–1.71).
Table 1
Bivariate analyses of factors associated with reports of police beatings among IDU in Bangkok, Thailand (
n = 639)
Calendar year of study enrolment
| | | |
2011 | 144 (43.4%) | 188 (56.6%) | 1.39 (1.13–1.71) | 0.002 |
2009 | 96 (31.3%) | 211 (68.7%) | | |
Sociodemographic characteristics
| | | |
Age
| | | | |
< 37 years old | 119 (38.3%) | 192 (61.7%) | 1.04 (0.85–1.27) | 0.720 |
≥ 37 years old | 121 (36.9%) | 207 (63.1%) | | |
Gender
| | | | |
Male | 227 (46.7%) | 259 (53.3%) | 5.50 (3.24–9.33) | <0.001 |
Female | 13 (8.5%) | 140 (91.5%) | | |
Income from drug dealing*
| | | | |
Yes | 21 (43.8%) | 27 (56.3%) | 1.18 (0.84–1.65) | 0.335 |
No | 219 (37.1%) | 372 (62.9%) | | |
Drug use behaviour
| | | | |
Heroin injection ever
| | | | |
Yes | 228 (40.3%) | 338 (59.7%) | 2.45 (1.45–4.15) | <0.001 |
No | 12 (16.4%) | 61 (83.6%) | | |
Midazolam injection ever
| | | | |
Yes | 210 (40.0%) | 315 (60.0%) | 1.52 (1.10–2.10) | 0.011 |
No | 30 (26.3%) | 84 (73.7%) | | |
Methamphetamine injection ever
| | | |
Yes | 180 (39.6%) | 274 (60.4%) | 1.22 (0.96–1.55) | 0.097 |
No | 60 (32.4%) | 125 (67.6%) | | |
Crystal methamphetamine injection ever
| | |
Yes | 48 (51.6%) | 45 (48.4%) | 1.47 (1.17–1.84) | <0.001 |
No | 192 (35.2%) | 354 (64.8%) | | |
Syringe sharing ever
| | | | |
Yes | 175 (47.0%) | 197 (53.0%) | 1.93 (1.52–2.45) | <0.001 |
No | 65 (24.3%) | 202 (75.7%) | | |
Experiences with criminal justice system
| |
Ever in prison
| | | | |
Yes | 220 (43.8%) | 282 (56.2%) | 3.00 (1.98–4.56) | <0.001 |
No | 20 (14.6%) | 117 (85.4%) | | |
Ever in compulsory drug detention
| | | |
Yes | 56 (47.1%) | 63 (52.9%) | 1.33 (1.06–1.66) | 0.012 |
No | 184 (35.4%) | 336 (64.6%) | | |
Healthcare access
|
Ever accessed methadone treatment
| | |
Yes | 200 (42.2%) | 274 (57.8%) | 1.74 (1.30–2.33) | <0.001 |
No | 40 (24.2%) | 125 (75.8%) | | |
Reporting barriers to accessing healthcare
| | |
Any | 158 (44.6%) | 196 (55.4%) | 1.55 (1.25–1.93) | <0.001 |
None | 82 (28.8%) | 203 (71.2%) | | |
Health outcomes
| | | | |
HIV serostatus
| | | | |
Positive | 61 (47.3%) | 68 (52.7%) | 1.35 (1.08–1.67) | 0.007 |
Negative or unknown | 179 (35.1%) | 331 (64.9%) | | |
Non-fatal overdose ever
| | | | |
Yes | 81 (52.6%) | 73 (47.4%) | 1.60 (1.32–1.95) | <0.001 |
No | 159 (32.8%) | 326 (67.2%) | | |
Table
2 shows the results from the final multivariate log-binomial regression model. As shown, an interaction was found with median age and a history of methamphetamine injection. Reports of police beatings were independently and positively associated with younger age (< 37 years) among those who never injected methamphetamine (adjusted prevalence ratio [APR]: 1.69; 95% CI: 1.17–2.43); male gender (APR: 4.43; 95% CI: 2.63–7.49); a history of syringe sharing (APR: 1.44; 95% CI: 1.15–1.80); a history of incarceration (APR: 2.51; 95% CI: 1.68–3.77); a history of compulsory drug detention (APR: 1.22; 95% CI: 1.05–1.40); reporting barriers to accessing healthcare (APR: 1.23; 95% CI: 1.01–1.49); and study enrolment in 2011 (APR: 1.27; 95% CI: 1.07–1.49).
Table 2
Multivariate log-binomial regression analysis of factors associated with reports of police beatings among IDU in Bangkok, Thailand (
n = 639)
Calendar year of study enrolment
| | | |
(2011 vs. 2009) | 1.27 | (1.07–1.49) | 0.005 |
Younger age among those who ever injected methamphetamine
| |
(< 37 years vs. ≥ 37 years old) | 1.18 | (0.99–1.41) | 0.062 |
Younger age among those who never injected methamphetamine
| |
(< 37 years vs. ≥ 37 years old) | 1.69 | (1.17–2.43) | 0.005 |
Gender
| | | |
(Male vs. Female) | 4.43 | (2.63–7.49) | <0.001 |
Syringe sharing ever
| | | |
(Yes vs. No) | 1.44 | (1.15–1.80) | 0.002 |
Ever in prison
| | | |
(Yes vs. No) | 2.51 | (1.68–3.77) | <0.001 |
Ever in compulsory drug detention
| | | |
(Yes vs. No) | 1.22 | (1.05–1.40) | 0.008 |
Reporting barriers to accessing healthcare
| | |
(Any vs. None) | 1.23 | (1.01–1.49) | 0.043 |
Non-fatal overdose ever
| | | |
(Yes vs. No) | 1.14 | (0.97–1.34) | 0.115 |
In sub-analysis, among participants completing surveys in 2011 (n = 144), 68.1% reported experiencing police beating while being interrogated, 43.1% reported being beaten during their arrest, 22.9% were beaten while being searched, and 22.9% reported having been beaten while in police holding cells.
Discussion
We found that over one-third of a sample of IDU in Bangkok reported having ever been beaten by police. Reports of police beating were independently associated with study enrolment in 2011, male gender, younger age among those who never injected methamphetamine, a history of incarceration, compulsory drug detention and syringe sharing, and reporting barriers to accessing healthcare. Participants most commonly experienced police beating during the interrogation process.
To our knowledge, the present study is the first to quantitatively examine the prevalence and correlates of experiencing physical violence at the hands of police among IDU in Thailand. The findings that the overall prevalence was as high as 37.6% in 2009–2011, and the majority of the victims (68.1%) experienced it during the interrogation process raise serious concern about widespread police-perpetrated abuses against this population. Our findings are consistent with previous reports during the 2003 “war on drugs” campaign indicating that police beating was used as a tactic to extract confessions of drug-related crimes from suspected drug users [
13]. We also found persistent reports of recent experiences with police beatings during the two-year study period. Furthermore, in a multivariate analysis, after extensive adjustment for social, demographic and behavioural factors, study enrolment in 2011 remained independently associated with reports of police beatings. Although the present study did not set out to assess the incidence of police beatings, these findings suggest that this form of police violence has continued in recent years.
We also found that male IDU experienced police beating more often than women. Thai police are believed to profile IDU based on factors such as track marks [
13]. As the great majority of Thai IDU population is believed to be comprised of males [
29], male IDU may be more susceptible to police profiling of IDU and police-perpetrated physical violence. However, it is also important to note that women may have been susceptible to other forms of police violence, such as sexual violence, which were not examined in the present study. We also found that younger IDU who never injected methamphetamine were more likely to have been beaten by police. Given that young people are a major target of drug demand reduction efforts in Thailand [
30], young IDU may be more vulnerable to police beatings. However, the reasons why this association was found only among those who never injected methamphetamine remain unknown. Future research should seek to explore the context of police beatings in more depth.
Of particular concern is the finding that reports of police beating were independently associated with a history of incarceration and compulsory drug detention. This finding, considered alongside our data concerning the circumstances of police beatings, suggests that IDU in this setting may typically experience police beating before being sent to prison or compulsory drug detention. This is concerning because these institutions may be ill equipped to deal with physical and psychological manifestations of traumatic injuries [
8]. Alternatively, the finding may suggest that individuals with a history of incarceration or compulsory drug detention are easier targets for police. Indeed, previous reports documented widespread use of “blacklists” by the Thai police during the 2003 “war on drugs” campaign, on which individuals with records of drug-related arrests were listed as suspected drug users or traffickers [
13]. More recent reports also suggested the continued use of blacklists by police [
18,
31], indicating that the latter interpretation may be also plausible.
Importantly, episodes of police beating were also independently associated with syringe sharing and reporting barriers to accessing health services. Consistent with previous studies from other settings indicating the negative impact of aggressive drug law enforcement on seeking health and harm reduction services by IDU [
2,
19,
20], our findings may suggest that individuals who experienced police beating may have retreated into more hidden settings where it was difficult to obtain sterile syringes, making the adoption of harm reduction practices become difficult or impossible. Several lines of evidence support such negative impacts of police beatings on HIV risk behaviour among IDU. Specifically, previous studies from Ukraine also found a significant association between police beatings and syringe sharing among IDU [
32,
33], and mathematical modelling showed that the elimination of police beatings could substantially avert HIV infection in this population [
33]. In addition, a recent study of IDU in Bangkok demonstrated that past experiences with police beatings were independently associated with recent syringe sharing, indicating a lasting effect of police beatings on HIV risk behaviour among IDU in this setting [
34]. It may also be that acts of violence by police create environment that promotes fear and constrains Thai IDUs’ access to healthcare. However, as the present study did not assess the temporal relationship between police beatings and health-seeking practices, future research should further examine this relationship in this setting.
Our findings have implications for policies and programs related to drug law enforcement in Thailand. First, the extent of police beating reported in the present study raise concern about widespread violations of basic human rights of IDU in this setting, including the rights to security of the person (Article 9) and to freedom from torture and cruel, inhuman, and degrading treatment (Article 7) under the International Covenant on Civil and Political Rights, to which Thailand became a party in 1996. The use of torture is also prohibited under Section 32 of the
Constitution of the Kingdom of Thailand B.E. 2550[
35]. In keeping with the law, a greater oversight of police operations should be a priority for the Thai government. Second, given the findings that police beating may be undermining HIV prevention among IDU in this setting, more efforts should be made to harmonize drug law enforcement activities and public health goals. Some examples of such efforts proposed and made in other settings include encouraging police officers to exercise discretion or cautioning or other measures instead of arresting street-level drug users [
36]; training police officers to engage in or at least not undermine harm reduction activities [
37,
38]; and establishing multi-sectoral partnerships between police and health agencies [
38,
39]. However, evaluations of these efforts showed some mixed results, pointing out various barriers to implementation, including personnel transfers, police culture, variations in public perception of the role of police, and ongoing police corruption [
2,
39,
40]. There is clearly a need for more work in this area. Lastly, ensuring access to legal services among IDU is important in order to help victims of police abuse obtain redress and compensation in this setting. In addition, a recent review indicated that expanded legal services also have potential to prevent police abuse and promote health benefits among IDU [
41].
This study has several limitations. First, due to the cross-sectional study design, we were unable to assess temporal relationships between the outcome and explanatory variables. Second, the self-reported data may have been affected by socially desirable responding or recall bias. Third, as the study sample was not randomly selected, our findings may not be generalizable to other populations of IDU in Thailand.
Acknowledgements
We would particularly like to thank the staff and volunteers at the Mitsampan Harm Reduction Center, Thai AIDS Treatment Action Group and O-Zone House for their support and Dr. Niyada Kiatying-Angsulee of the Social Research Institute, Chulalongkorn University, for her assistance with developing this project. We also thank Tricia Collingham, Deborah Graham, Caitlin Johnston, Calvin Lai and Peter Vann for their research and administrative assistance, and Prempreeda Pramoj Na Ayutthaya, Arphatsaporn Chaimongkon and Sattara Hattirat for their assistance with data collection. The study was supported by Michael Smith Foundation for Health Research. This research was also undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports EW. KH is supported by the University of British Columbia Doctoral Fellowship.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KH and TK designed the study. KH conducted the statistical analyses, drafted the manuscript, and incorporated suggestions from all co-authors. All authors made significant contributions to the conception of the analyses, interpretation of the data, and drafting of the manuscript. All authors read and approved the final manuscript.