Journal of Substance Abuse Treatment, Vol. 9, pp. 171-176, 1992 Printed in the USA. All rights reserved.
INTERNATIONAL
Copyright 0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
PERSPECTIVE
Has Malaysia’s Antidrug Effort Been Effective? JAMES
F. SCORZELLI,
PhD
Rehabilitation Counseling Program, Northeastern University, Boston, Massachusetts
Abstract-It
is a common belief that a massive effort in law enforcement, preventive education and rehabilitation will result in the elimination of a country’s drug problem. Based on this premise, Malaysia in 1983 implemented such a multifaceted anti-drug strategy, and the results of a 1987 study by the author suggested that Malaysia’s effort had begun to contribute to a steady decrease in the number of identified drug abusers. Although the number of drug-addicted individuals declined, the country’s recidivism rates were still high. Because of this high relapse rate, Malaysia expanded their rehabilitation effort and developed a community transition program. In order to determine the impact of these changes on the country’s battle against drug abuse, a follow-up study was conducted in 1990. The results of this study did not clearly demonstrate that the Malaysian effort had been successful in eliminating the problem of drug abuse, and raised some questions concerning the effectiveness of the country’s drug treatment programs. Keywords-Malaysia;
drug treatment;
preventive
education;
effectiveness.
drug-addicted individuals and the country’s recidivism rates.
that a massive effort in law enforcement, preventive education, and rehabilitation will result in the elimination of a country’s drug problem. Based on this premise, Malaysia in 1983 implemented such a multifaceted antidrug strategy, and the results of a 1987 study by the author suggested that Malaysia’s effort had begun to contribute to a steady decrease in the number of identified drug-addicted individuals (Scorzelli, 1988). Although the number of newly identified addicted individuals declined, the country’s recidivism rates were still high. Because of this high relapse rate, Malaysia expanded their rehabilitation effort and developed a community transition program for those persons who had completed their rehabilitation program. In order to determine the impact of these changes on Malaysia’s battle against drug abuse, a follow-up study was conducted in 1990. As in the prior study (Scorzelli, 1988), the major criteria used to measure effectiveness of Malaysia’s antidrug strategy was the number of newly identified IT IS A COMMON BELIEF
BACKGROUND
Because of the rapid increase of drug abuse in Malaysia, the prime minister of the country declared the drug problem a national emergency on February 19, 1983, and initiated a massive effort in law enforcement, preventive education, and rehabilitation. Although Malaysia is not a producer of illegal drugs, the country’s location with respect to the Golden Triangle has resulted in it being a major trafficking and transshipment area. The Golden Triangle, composed of Burma, Thailand, and Laos, is the world’s third-largest producer of heroin, and a large part of the heroin is used internally (Walsh, 1981). Malaysia’s drug laws are very stringent in that there is a mandatory death penalty for trafficking (defined as possession of 15 grams of heroin or morphine, 1,000 grams of opium, or 200 grams of marijuana). While the international media have focused on these tough drug laws in describing the country’s drug problem, Malaysia’s major effort in curtailing drug abuse has been its preventive education and rehabilitation programs. Specifically, there is compulsory treatment for all drug abusers, and
This study was supported by a World Health Organization Fellowship. Requests for reprints should be addressed to James F. Scorzelli, PhD, Professor & Director, Rehabilitation Counseling Program, Human Services Program, 210 Lake Hall, Northeastern University, Boston, MA 02115. 171
J. F. Scorzelli
172
the country’s Drug Dependent Treatment Act of 1983 clearly defined drug abuse as an illness and not as criminal behavior.
TABLE 2 Recidivism Rates of Drug Abusers in Malaysia from 1983-l 989
Repeaters
INCIDENCE/PROFILE
OF DRUG ABUSER
From 1970 to the end of 1989, 145,411 Malaysians have been registered as drug abusers (refer to Table 1). The country has a computerized central registry, and this National Drug Information System has collected data on the incidence and profiles of drug abusers since 1983. In 1987, this data bank was transferred from one of the country’s universities to the government agency called the Anti-Dadah Task Force (dadah means dangerous drugs). The National Drug Information System, besides its role in the detection and subsequent monitoring of drug addicted individuals, is also used in developing an epidemiology of drug addiction and the evaluation of the country’s treatment programs (Anti-Dadah Task Force, 1989). As shown in Table 1, it appears that the number of newly identified drug abusers have plateaued at around 7,000 a year. The relatively significant increase in the number of drug abusers identified in 1988 appears to be inconsistent with the trend, and the official government explanation is that this increase was due to a massive enforcement effort in preparation for “Visit Malaysia Year” in 1990 - promotion to increase tourism (AntiDadah Task Force, 1989). Regardless of the validity of this explanation, the leveling off of the number of drug addicts appears to be the consensus of both the government and the drug experts in the country. However, the recidivism rates remains high, and 60.7% of the drug addicted individuals identified in 1989 were
TABLE 1 Number of Malaysians Detected for Drug Abuse, 1970-l 989
Year
Type of Drug (%) Male Female Number % % Heroin Cannabis Other
1970-75 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989
12,468 9,850 8,047 8,114 8,299 7,154 10,391 13,363 14,624 11,915 9,591 7,329 7,596 9,710 6,960
97.6 98.2 97.7 98.8 97.1 97.0 97.3 97.4 98.5 99.1 98.4 97.7 97.3 97.4 97.9
2.4 1.8 2.3 3.2 2.9 3.0 2.7 2.6 1.5 .9 1.6 2.3 2.7 2.6 2.1
78.3 81 .O 88.4 84.2 81.2 82.7 82.6 82.4 77.4 72.0 75.1 73.6 74.2 80.0 84.0
16.6 16.7 8.8 7.3 9.3 10.5 12.6 13.1 12.8 15.1 15.8 15.2 14.7 13.8 7.8
5.1 2.3 2.8 8.5 9.5 6.8 4.8 4.5 8.2 12.9 9.1 11.2 10.1 6.2 8.2
Note. Within the “Other” category of Type of Drug, opium and morphine comprised the largest proportion. Source: Anti-Dadah Task Force (1989).
Year 1983 1984 1985 1986 1987 1988 1989
Total Number of Drug Abusers 28,245 19,901 21,552 17,058 16,335 21,856 17,729
Number
Percentage
11,821 7,926 11,961 9,729 8,739 12,146 10,769
44.3 39.8 55.5 57.0 53.5 55.6 60.7
Source: Anti-Dadah Task Force (1989).
repeaters (refer to Table 2). The profile of a typical drug abuser is a male heroin user in his mid-20s who has dropped out of school and works as a laborer or is unemployed (Anti-Dadah Task Force, 1989). Specifically, in 1989, 97.9% of all drug abusers were male, heroin was the major drug of abuse among 84% of these individuals, and 52% were between 20 and 29 years of age. Although the racial breakdown of the drug abuser used to be reported to the public, this practice was stopped in 1987 because it was considered “too sensitive” by the government. Because of the multiracial nature of Malaysia (consisting of approximately 45% Malays, 38% Chinese, 11% Indians, and 7% indigenous groups) and the country’s status as a developing nation, the government has become very cautious when the question of race and drug addiction is raised. Yet, in 1983, it was reported that 48.2% of the Malays, 27.1% of the Chinese, and 13.1% of the Indians were drug abusers (Haji Kamaruddin bin Ngah, 1984). Since 1985, there has been an increase in the intravenous injection of heroin, with approximately 20% of the addicted individuals using this method of intake (Anti-Dadah Task Force, 1989; Deva, 1988). Prior to 1985, the major method of intake was “spiking” or mixing the narcotic with cigarette tobacco. The changing trend in the method of drug usage appears to be related to its availability. Specifically, drug seizures for heroin have increased, with 295 kg confiscated in 1989 (Haji Shariff Osman, 1990). As a result, the street price has increased (200%) and the purity of the heroin sold has decreased from 25% to 16% (Anti-Dadah Task Force, 1989). Therefore, injection of heroin provides the Malaysian drug addicted individual a more efficient method of obtaining the desired effect. Due to the sharing of dirty needles, there are now 150 addicted males and 2 addicted females in the treatment program who are infected with HIV (Jit Singh, personal communication, July 16, 1990). Prior to 1987, a HIV-positive diagnosis among drug abusers
173
Has Malaysia’s Antidrug Effort Been Effective?
was nonexistent. Yet, consistent with the world-wide AIDS epidemic, there have been 510 confirmed HIV cases in Malaysia since 1987. Of this group, 14 people contracted AIDS, of whom 10 have died (Jit Singh, personal communication, July 16, 1990). Because of the need for medical management, the government is planning to segregate these individuals in a special facility near the country’s capital of Kuala Lumpur. The surfacing of HIV among Malaysia’s drug users is a serious concern and a new development in the country’s battle against drug abuse. REHABILITATION
Although rehabilitation in Malaysia involves both governmental and voluntary agencies, the major treatment thrust is the government rehabilitation facilities. Specifically, there is compulsory treatment for all drug abusers, involving a maximum of 2 years in a rehabilitation center, followed by 2 years of supervised aftercare. It is important to note that the government facilities are composed of those drug abusers who have volunteered for treatment or have been identified as using an illegal drug (via urine test). Persons found with drugs on their possession are prosecuted under the country’s drug laws and undergo a similar rehabilitation program while incarcerated. The voluntary agencies are primarily religiously based or involve the use of traditional medicine. They range from day programs to residential facilities and are primarily utilized during aftercare. The government drug rehabilitation centers involve a holistic treatment approach, which attempts to reshape the drug abuser in all aspects of his or her life, with inmates receiving the following services: 1. Physician restoration a. orientation and intake (if there is addiction to an opiate, detoxification is done by “cold turkey,” unless a person is over 55 years of age or has medical complications). b. evaluation C. calisthenics, physical training, and paramilitary training d. moral guidance and religious instruction e. vocational and recreational therapy f. psychological services, including individual, group, and family counseling g. review and discharge. The rehabilitation centers were modeled after the therapeutic community concept of drug treatment and are very regimented. They utilize a phase system in that an inmate can progress to a higher stage, with more responsibility and privileges based on his or her behavior. Each phase is identified by a different color shirt, with the attainment of the highest phase (Phase 4) resulting in weekend passes, and an opportunity to assume a leadership position at the center and to secure
TABLE 3 Phase System at the Rehabilitation
Centers in Malaysia
Phase 1 (O-5 months) 1 Orientation 2. Religious education 3. Military drill (4 hours daily) 4. Civics course 5. Recreation 6. Counseling Phase 2 (6-10 months) 1. Religious education 2. Counseling 3. Military drill 4. Civics course 5. Recreation 6. Vocational training Phase 3 (11-l 5 months) 1. Same as Phase 2, except that community projects are organized so as to integrate the resident into society. Phase 4 (16-24 months) 1. Religious education 2. Counseling 3. Military drill (1 hour daily) 4. Civics course 5. Vocational training 6. Recreation 7. Review for discharge
employment prior to discharge (refer to Table 3). At present, there are 17 rehabilitation centers in the country, and 11 new centers have been opened since 1987. These centers now house close to 4,000 persons, and close to half of them are over capacity. Therefore, the government plans to open four more rehabilitation centers within the next two years. Until 1988, all of the rehabilitation centers were for men. At that time, the country opened its first rehabilitation center for women. This center has 115 inmates, and except for less strenuous physical training, the women follow the same phase system as do the men. Unlike the typical drug-addicted male, these women are older (average age of 35 years), and 75% are married (there are two infants in the center). Furthermore, 70% of the women have been identified as being prostitutes (Siti Rohauah Othman, personal communication, July 18, 1990). Beginning in 1987, all of the rehabilitation centers became one-stop centers. A one-stop center includes a joint effort among all government ministries, in that as soon as a person has been identified as a drug abuser (by a urine test and medical certification at a general or district hospital), he or she is brought to the center, where a magistrate issues a detection order. If addicted to an opiate, detoxification begins, and once the inmate is certified to be medically fit, he or she begins the treatment program as listed above. It has been reported that the government spends approximately 7.5 million dollars a year on drug rehabil-
J.F. Scorzelli
174
itation (Haji Shariff Osman, 1990), and considering that the population of the country is 17 million, this is a relatively large influx of funds. Because of this high cost, the goal of the government is to make all the rehabilitation centers self-sufficient. In order to obtain this goal of self-support, all of the centers have developed methods of earning revenue. This has ranged from selling their agricultural products and crafts to participating in small construction projects. A unique enterprising project initiated by one center was the development of a guest house within the city that is adjacent to the rehabilitation center. This small hotel can house six guests, and is entirely operated by the inmates (Phase 4) from the center. It is felt that such business ventures will help defray some of the operating costs of rehabilitation centers. However, the author found that the highest proportion that a center has been able to contribute to its operating costs was 35%. In order to combat the high recidivism rates among drug abusers and to foster community transition, the government developed a system of aftercare houses in 1987. Presently, there are 36 aftercare houses in the country, and the goal is to have 66 of these facilities in operation by 1992. Each aftercare house is administered by a rehabilitation center, and the residents are persons who are in Phase 4 of their treatment program or have just been discharged. The aftercare houses are similar to the halfway houses in the United States, and are not as regimented as the rehabilitation centers. Admittance to an aftercare house is based on the recommendation of the director of the rehabilitation center. The average length-of-stay for a resident is usually 8 months, but there is really no time limit on how long a person can live at the facility. Discharge from the aftercare house is voluntary, and occurs when the resident feels that he or she is ready to make the transition to the community. While living in an aftercare house, the resident receives counseling services and is involved in a variety of work programs. Besides fostering community transition, another aim of the aftercare houses is to supplement the difficult task of monitoring the two year aftercare supervision that is required of all persons who are discharged from the rehabilitation centers. Presently, the average caseload of an aftercare officer is 200, and this probably accounts for why the government loses contact with close to 40% of those inmates who have been discharged from the rehabilitation centers (Anti-Dadah Task Force, 1989). PREVENTIVE
DRUG EDUCATION
Preventive drug education in Malaysia involves the governmental Ministries of Education, Information, and Youth and Sports. These ministries attempt to increase public awareness of the dangers and conse-
quences of drug addiction (Anti-Dadah Task Force, 1989). Since 1984, preventive drug education programs have been implemented in the public schools, community, and work place. Drug abuse does not appear to be a problem in Malaysia’s public schools. In 1989, only 2% of the registered drug abusers were public school students (AntiDadah Task Force, 1989). Drug prevention education in the primary and secondary schools is integrated within courses that focus on health promotion, and in a variety of co-curriculum activities. Health promotion in the schools integrate drug prevention education in courses that deal with personal hygiene, living skills, citizenship, and the development of positive family and interpersonal relationships (Foong, Maznah, Navaratnam, &Kong, 1986; Ministry of Education, 1987). There are numerous co-curriculum activities that deal with drug prevention, and those activities that have been implemented within the last 3 years are as follows: Peer counseling program. The program, which began in 1988, involves a 5-day training session for students who have been identified by their headmasters and teachers as potential leaders. Student colloquia. In 1988, two workshops for secondary students were held. The workshops emphasized interpersonal skills development, and the participants were given the opportunity to discuss the drug problems encountered by students in their schools and effective preventive strategies. The colloquia have been expanded and are held every year. Antidntg badge scheme. The program began in 1988 and involves all the uniformed organizations (i.e., boy scouts) in the country. Within the last two years, 96 students received badges for a wide variety of antidrug activities. Holiday work camps. Because there are a large number of abusers who have dropped out of school, the Ministry of Youth and Sports conducts holiday work camps during the school breaks. These camps are composed of school children who are viewed by their teachers as being at high risk for dropping out of school (poor grades and behavior). There were 16 one-week camps held in 1988, involving 1,600 students. The stated purpose of these camps is to develop the self-confidence of these children by strengthening their national and spiritual values. In addition to these co-curriculum activities, a random urine testing program has been introduced into the secondary schools. This program began in 1988, with 60 schools being screened. Presently, random urine testing involves all the secondary schools and occurs twice a year. It is also important to note that random urine testing is required of all government employees, civil service job applicants, and recipients of grant awards. The community-based preventive drug education programs are directed at government officials and cit-
175
Has Malaysia% Antidrug Effort Been Effective?
izens at the local level. For the most part, these programs have consisted of in-service training on the methods of disseminating information about drug abuse to the public and a variety of publicity activities that focus on drug abuse prevention. The country’s major voluntary organization, called Pemadam, is most clearly identified with these community activities. The organization was formed in 1976, and although private, Pemadam is closely associated with the government (the prime minister has the responsibility of appointing the national president). Pemadam works with all the religious, social, and welfare groups, civic organizations, and private industry. Some of its many preventive drug education functions include the dissemination of cassette tapes, films, and brochures; the organization of seminars, mobile exhibits, and competitions with antidrug themes (i.e., poster, song contests, etc.); and the operation of aftercare camps. A relatively new development in Malaysia’s preventive effort occurred in 1987, with the initiation of a program called, Concentrated and Integrated Projects. This government project categorized various areas in the country as either “black” or “white” based on the severity of the drug problem in the region. If an area is targeted as “black,” all preventive drug education and enforcement activities are intensified. In order to strengthen the dissemination of information about drug abuse, a program for training key communicators was developed in 1988. In this program, formerly drug-addicted individuals who have recovered are trained as public speakers and are sent to local community and school functions to discuss their views about the prevention of drug abuse. In 1989, two of these key communicators formed a self-help group similar to Narcotics Anonymous, and the group has grown from 3 to 30 members. In 1987, a training program in drug abuse counseling was developed for all governmental agencies. The goals of the program were to increase the knowledge and awareness of senior personnel managers on the drug situation in the country and to provide them with a basic understanding of counseling to enable them to detect and help their colleagues and staff who may be involved in drug abuse. The first course was given to 28 managers, and this was followed by six similar training courses for personnel managers from both government agencies and the private sector. Finally, in order to consolidate all financial contributions made by companies, institutions, and individuals to drug abuse prevention, an antinarcotics trust account was formed in 1987. This fund is managed by the prime minister’s department, and the tax-exempt monies have been used for the drug abuse prevention colloquia for secondary students, for production of a video tape describing the country’s antidrug initiative, and for the publication of a drug abuse prevention
manual for employers in the private sector (AntiDadah Task Force, 1989). DISCUSSION
From the information gathered in this follow-up study, it is difficult to make any definite conclusions concerning the success of Malaysia’s antidrug strategy. However, there does appear to be some trends which would merit discussion. First of all, even if one takes into account the large increase in the number of drug abusers in 1988, there does appear to be sufficient evidence of a decline in the number of Malaysians detected for drug abuse. In the same manner, the contention that the incidence of drug abuse has plateaued also seems to be valid. Although this trend is very encouraging, the high recidivism rates are not. In fact, it appears that as Malaysia’s drug rehabilitation programs expand, so does the relapse rate of drug abuse. This “revolving door” syndrome in the treatment of the drug-addicted individual in general has been welldocumented (Miller & Hester, 1988; Sobell & Sobell, 1980) and is evident in the Malaysian antidrug effort. The official government explanation for the high recidivism is that it is due to the lack of rehabilitation facilities and aftercare workers. This explanation can be supported by the large number of rehabilitation centers that are over capacity, as well as the large caseloads of the aftercare workers. As a result of this situation, the government continues to open more rehabilitation centers and aftercare houses. Another factor that may be related to the high relapse rate among drug abusers is simply that the country’s rehabilitation system is not effective. Malaysia has committed itself to the therapeutic community treatment concept, and it is possible that this approach may not be suitable for all drug abusers. That is, there are no methadone treatment or hospital programs for drug addicted individuals in Malaysia. However, there really is no clear evidence that one drug treatment approach is any better or worse then another (Miller & Hester, 1988; U.S. Department of Health and Human Services, 1981). Even though Malaysia has not relinquished its treatment model, many professionals feel that their treatment effort is being hindered by grouping all types of drug abusers in the same facility (Haji Shariff Osman, 1990). That is, it is felt that “hard core” addicted individuals can have a detrimental effect on those persons who have entered a rehabilitation center for first time. Therefore, there has been a recommendation for segregating rehabilitation center inmates based on their previous history of drug abuse (Haji Shariff Osman, 1990). In the same manner, there has even been a proposal to separate the “hard core” addicted individual from society for the rest of his or her life (Mohamed Zaini Rahman, personal
176
communication, July 13, 1990). Briefly, the proposal involved the development of a self-sufficient community that would be composed of only these drug abusers and their families. With some thought, this suggestion is similar to the philosophy of Synannon when it was first founded (Deissler, 1970). The last explanation that may explain Malaysia’s high recidivism rates pertain to the nature of drug addiction itself. It is a commonly held belief that drug addiction is a disease that has no cure and can only be controlled. As a result, relapse is to be expected and is part of the recovery process. Malaysia has rejected the disease concept of addiction and views drug addiction as social deviancy. Furthermore, the length of time that a person says he or she has been drug free before a relapse occurs is not tabulated by the National Drug Information System. Therefore, it appears that the length of time that a person has remained drug free is not a significant factor in Malaysia’s treatment philosophy. Instead, rehabilitation success seems to be based on lifetime abstinence from drugs. Because of the high recidivism rates for drug abuse, it is difficult to state that Malaysia’s rehabilitation programs have been effective. In fact, one could make the argument that the observed decline in the incidence of drug abuse is the result of the country’s strong law enforcement and/or preventive education efforts. Similarly, Malaysia’s 7-year battle against drug abuse raises further questions about the validity of the common belief that a massive effort in law enforcement, preventive education, and rehabilitation will result in the elimination of a country’s drug problem. This is especially applicable as one reviews the antidrug strategies put forth by former President Reagan and President Bush. Even taking into account the politicalcultural differences of both countries, there are many components of the Malaysian system that have been proposed or implemented in the American effort, including such things as a death penalty for traffickers and the use of paramilitary training in treatment. In fact, the major criticism of the American omnibus antidrug bill has been the over-emphasis placed on law
J. F. Scorzelli
enforcement and the lack of funding for drug treatment programs. However, even though the Malaysian rehabilitation effort has received unrestricted government funding, there is still no indication that it has been successful. REFERENCES Anti-Dadah Task Force. (1989). Luporan dud&r (drug report). Kuala Lumpur, Malaysia: Author. Deissler, K. (1970). Synannon: Its concept and methods. Drug Dependence, 5, 28-35. Deva, M.P. (1988, November). The missing link in drug dependence prevention in Muluysiu. Paper presented at the 10th INFGG Conference: From Global Commitment to Community Action, Kuala Lumpur, Malaysia. Foong, C.P., Maznah, I., Navaratnam, V., SCKong, H.S. (1986). A comparative study of the psychosocial profile of drug using and non-drug using school children. Pinang, Malaysia: National Drug Research Center, University of Science, Malaysia. Haji Kamaruddin bin Ngah. (1984, December). Satu masulah yang penuh dengan cabaran (Results of treatment). Paper presented at the conference, Kaunselin Dalam Pemulihan Dadah (Counseling With Drug Addicts), Bangi, Malaysia. Haji Shariff Osman. (1990, July). Dangerous mix. Paper presented at the National Drug Treatment and Rehabilitation Seminar, Kuala Lumpur, Malaysia. Miller, W.R., &Hester, R.K. (1988). The effectiveness of alcoholism treatment: What research reveals. In W.R. Miller & R.K. Hester (Eds.), Treating addictive behaviors: Processes of change (pp. 121-174). New York: Plenum Press. Ministry of Education. (1987). Drugprevention educationprograms in Malaysian school system. Kuala Lumpur, Malaysia: Author. Scorzelli, J.F. (1988). Assessing the effectiveness of Malaysia’s drug prevention education and rehabilitation programs. Journal of Substance Abuse Treatment, 5, 253-262. Sobell, L.C., & Sobell, M.B. (1980). Convergent validity: An approach to increasing confidence in treatment outcome conclusions with alcohol and drug abusers. In I.C. Sobell, M.B. Sobell, and E. Ward (Eds.), Evaluating alcohol and drug abuse treatment effectiveness: Recent advances (pp. 177-183). New York: Pergamon Press. U.S. Department of Health of Human Services. (1981). Comparutive effectiveness of drug abuse treatment modalities (DHHS Publication No. 81-1067). Washington, DC: U.S. Government Printing Office. Walsh, W.D. (1981). Importance of Iraqi-Iranian conflict. Drug Enforcement, 8, 7-12.
INTERNATIONAL
Copyright 0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
PERSPECTIVE
Has Malaysia’s Antidrug Effort Been Effective? JAMES
F. SCORZELLI,
PhD
Rehabilitation Counseling Program, Northeastern University, Boston, Massachusetts
Abstract-It
is a common belief that a massive effort in law enforcement, preventive education and rehabilitation will result in the elimination of a country’s drug problem. Based on this premise, Malaysia in 1983 implemented such a multifaceted anti-drug strategy, and the results of a 1987 study by the author suggested that Malaysia’s effort had begun to contribute to a steady decrease in the number of identified drug abusers. Although the number of drug-addicted individuals declined, the country’s recidivism rates were still high. Because of this high relapse rate, Malaysia expanded their rehabilitation effort and developed a community transition program. In order to determine the impact of these changes on the country’s battle against drug abuse, a follow-up study was conducted in 1990. The results of this study did not clearly demonstrate that the Malaysian effort had been successful in eliminating the problem of drug abuse, and raised some questions concerning the effectiveness of the country’s drug treatment programs. Keywords-Malaysia;
drug treatment;
preventive
education;
effectiveness.
drug-addicted individuals and the country’s recidivism rates.
that a massive effort in law enforcement, preventive education, and rehabilitation will result in the elimination of a country’s drug problem. Based on this premise, Malaysia in 1983 implemented such a multifaceted antidrug strategy, and the results of a 1987 study by the author suggested that Malaysia’s effort had begun to contribute to a steady decrease in the number of identified drug-addicted individuals (Scorzelli, 1988). Although the number of newly identified addicted individuals declined, the country’s recidivism rates were still high. Because of this high relapse rate, Malaysia expanded their rehabilitation effort and developed a community transition program for those persons who had completed their rehabilitation program. In order to determine the impact of these changes on Malaysia’s battle against drug abuse, a follow-up study was conducted in 1990. As in the prior study (Scorzelli, 1988), the major criteria used to measure effectiveness of Malaysia’s antidrug strategy was the number of newly identified IT IS A COMMON BELIEF
BACKGROUND
Because of the rapid increase of drug abuse in Malaysia, the prime minister of the country declared the drug problem a national emergency on February 19, 1983, and initiated a massive effort in law enforcement, preventive education, and rehabilitation. Although Malaysia is not a producer of illegal drugs, the country’s location with respect to the Golden Triangle has resulted in it being a major trafficking and transshipment area. The Golden Triangle, composed of Burma, Thailand, and Laos, is the world’s third-largest producer of heroin, and a large part of the heroin is used internally (Walsh, 1981). Malaysia’s drug laws are very stringent in that there is a mandatory death penalty for trafficking (defined as possession of 15 grams of heroin or morphine, 1,000 grams of opium, or 200 grams of marijuana). While the international media have focused on these tough drug laws in describing the country’s drug problem, Malaysia’s major effort in curtailing drug abuse has been its preventive education and rehabilitation programs. Specifically, there is compulsory treatment for all drug abusers, and
This study was supported by a World Health Organization Fellowship. Requests for reprints should be addressed to James F. Scorzelli, PhD, Professor & Director, Rehabilitation Counseling Program, Human Services Program, 210 Lake Hall, Northeastern University, Boston, MA 02115. 171
J. F. Scorzelli
172
the country’s Drug Dependent Treatment Act of 1983 clearly defined drug abuse as an illness and not as criminal behavior.
TABLE 2 Recidivism Rates of Drug Abusers in Malaysia from 1983-l 989
Repeaters
INCIDENCE/PROFILE
OF DRUG ABUSER
From 1970 to the end of 1989, 145,411 Malaysians have been registered as drug abusers (refer to Table 1). The country has a computerized central registry, and this National Drug Information System has collected data on the incidence and profiles of drug abusers since 1983. In 1987, this data bank was transferred from one of the country’s universities to the government agency called the Anti-Dadah Task Force (dadah means dangerous drugs). The National Drug Information System, besides its role in the detection and subsequent monitoring of drug addicted individuals, is also used in developing an epidemiology of drug addiction and the evaluation of the country’s treatment programs (Anti-Dadah Task Force, 1989). As shown in Table 1, it appears that the number of newly identified drug abusers have plateaued at around 7,000 a year. The relatively significant increase in the number of drug abusers identified in 1988 appears to be inconsistent with the trend, and the official government explanation is that this increase was due to a massive enforcement effort in preparation for “Visit Malaysia Year” in 1990 - promotion to increase tourism (AntiDadah Task Force, 1989). Regardless of the validity of this explanation, the leveling off of the number of drug addicts appears to be the consensus of both the government and the drug experts in the country. However, the recidivism rates remains high, and 60.7% of the drug addicted individuals identified in 1989 were
TABLE 1 Number of Malaysians Detected for Drug Abuse, 1970-l 989
Year
Type of Drug (%) Male Female Number % % Heroin Cannabis Other
1970-75 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989
12,468 9,850 8,047 8,114 8,299 7,154 10,391 13,363 14,624 11,915 9,591 7,329 7,596 9,710 6,960
97.6 98.2 97.7 98.8 97.1 97.0 97.3 97.4 98.5 99.1 98.4 97.7 97.3 97.4 97.9
2.4 1.8 2.3 3.2 2.9 3.0 2.7 2.6 1.5 .9 1.6 2.3 2.7 2.6 2.1
78.3 81 .O 88.4 84.2 81.2 82.7 82.6 82.4 77.4 72.0 75.1 73.6 74.2 80.0 84.0
16.6 16.7 8.8 7.3 9.3 10.5 12.6 13.1 12.8 15.1 15.8 15.2 14.7 13.8 7.8
5.1 2.3 2.8 8.5 9.5 6.8 4.8 4.5 8.2 12.9 9.1 11.2 10.1 6.2 8.2
Note. Within the “Other” category of Type of Drug, opium and morphine comprised the largest proportion. Source: Anti-Dadah Task Force (1989).
Year 1983 1984 1985 1986 1987 1988 1989
Total Number of Drug Abusers 28,245 19,901 21,552 17,058 16,335 21,856 17,729
Number
Percentage
11,821 7,926 11,961 9,729 8,739 12,146 10,769
44.3 39.8 55.5 57.0 53.5 55.6 60.7
Source: Anti-Dadah Task Force (1989).
repeaters (refer to Table 2). The profile of a typical drug abuser is a male heroin user in his mid-20s who has dropped out of school and works as a laborer or is unemployed (Anti-Dadah Task Force, 1989). Specifically, in 1989, 97.9% of all drug abusers were male, heroin was the major drug of abuse among 84% of these individuals, and 52% were between 20 and 29 years of age. Although the racial breakdown of the drug abuser used to be reported to the public, this practice was stopped in 1987 because it was considered “too sensitive” by the government. Because of the multiracial nature of Malaysia (consisting of approximately 45% Malays, 38% Chinese, 11% Indians, and 7% indigenous groups) and the country’s status as a developing nation, the government has become very cautious when the question of race and drug addiction is raised. Yet, in 1983, it was reported that 48.2% of the Malays, 27.1% of the Chinese, and 13.1% of the Indians were drug abusers (Haji Kamaruddin bin Ngah, 1984). Since 1985, there has been an increase in the intravenous injection of heroin, with approximately 20% of the addicted individuals using this method of intake (Anti-Dadah Task Force, 1989; Deva, 1988). Prior to 1985, the major method of intake was “spiking” or mixing the narcotic with cigarette tobacco. The changing trend in the method of drug usage appears to be related to its availability. Specifically, drug seizures for heroin have increased, with 295 kg confiscated in 1989 (Haji Shariff Osman, 1990). As a result, the street price has increased (200%) and the purity of the heroin sold has decreased from 25% to 16% (Anti-Dadah Task Force, 1989). Therefore, injection of heroin provides the Malaysian drug addicted individual a more efficient method of obtaining the desired effect. Due to the sharing of dirty needles, there are now 150 addicted males and 2 addicted females in the treatment program who are infected with HIV (Jit Singh, personal communication, July 16, 1990). Prior to 1987, a HIV-positive diagnosis among drug abusers
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Has Malaysia’s Antidrug Effort Been Effective?
was nonexistent. Yet, consistent with the world-wide AIDS epidemic, there have been 510 confirmed HIV cases in Malaysia since 1987. Of this group, 14 people contracted AIDS, of whom 10 have died (Jit Singh, personal communication, July 16, 1990). Because of the need for medical management, the government is planning to segregate these individuals in a special facility near the country’s capital of Kuala Lumpur. The surfacing of HIV among Malaysia’s drug users is a serious concern and a new development in the country’s battle against drug abuse. REHABILITATION
Although rehabilitation in Malaysia involves both governmental and voluntary agencies, the major treatment thrust is the government rehabilitation facilities. Specifically, there is compulsory treatment for all drug abusers, involving a maximum of 2 years in a rehabilitation center, followed by 2 years of supervised aftercare. It is important to note that the government facilities are composed of those drug abusers who have volunteered for treatment or have been identified as using an illegal drug (via urine test). Persons found with drugs on their possession are prosecuted under the country’s drug laws and undergo a similar rehabilitation program while incarcerated. The voluntary agencies are primarily religiously based or involve the use of traditional medicine. They range from day programs to residential facilities and are primarily utilized during aftercare. The government drug rehabilitation centers involve a holistic treatment approach, which attempts to reshape the drug abuser in all aspects of his or her life, with inmates receiving the following services: 1. Physician restoration a. orientation and intake (if there is addiction to an opiate, detoxification is done by “cold turkey,” unless a person is over 55 years of age or has medical complications). b. evaluation C. calisthenics, physical training, and paramilitary training d. moral guidance and religious instruction e. vocational and recreational therapy f. psychological services, including individual, group, and family counseling g. review and discharge. The rehabilitation centers were modeled after the therapeutic community concept of drug treatment and are very regimented. They utilize a phase system in that an inmate can progress to a higher stage, with more responsibility and privileges based on his or her behavior. Each phase is identified by a different color shirt, with the attainment of the highest phase (Phase 4) resulting in weekend passes, and an opportunity to assume a leadership position at the center and to secure
TABLE 3 Phase System at the Rehabilitation
Centers in Malaysia
Phase 1 (O-5 months) 1 Orientation 2. Religious education 3. Military drill (4 hours daily) 4. Civics course 5. Recreation 6. Counseling Phase 2 (6-10 months) 1. Religious education 2. Counseling 3. Military drill 4. Civics course 5. Recreation 6. Vocational training Phase 3 (11-l 5 months) 1. Same as Phase 2, except that community projects are organized so as to integrate the resident into society. Phase 4 (16-24 months) 1. Religious education 2. Counseling 3. Military drill (1 hour daily) 4. Civics course 5. Vocational training 6. Recreation 7. Review for discharge
employment prior to discharge (refer to Table 3). At present, there are 17 rehabilitation centers in the country, and 11 new centers have been opened since 1987. These centers now house close to 4,000 persons, and close to half of them are over capacity. Therefore, the government plans to open four more rehabilitation centers within the next two years. Until 1988, all of the rehabilitation centers were for men. At that time, the country opened its first rehabilitation center for women. This center has 115 inmates, and except for less strenuous physical training, the women follow the same phase system as do the men. Unlike the typical drug-addicted male, these women are older (average age of 35 years), and 75% are married (there are two infants in the center). Furthermore, 70% of the women have been identified as being prostitutes (Siti Rohauah Othman, personal communication, July 18, 1990). Beginning in 1987, all of the rehabilitation centers became one-stop centers. A one-stop center includes a joint effort among all government ministries, in that as soon as a person has been identified as a drug abuser (by a urine test and medical certification at a general or district hospital), he or she is brought to the center, where a magistrate issues a detection order. If addicted to an opiate, detoxification begins, and once the inmate is certified to be medically fit, he or she begins the treatment program as listed above. It has been reported that the government spends approximately 7.5 million dollars a year on drug rehabil-
J.F. Scorzelli
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itation (Haji Shariff Osman, 1990), and considering that the population of the country is 17 million, this is a relatively large influx of funds. Because of this high cost, the goal of the government is to make all the rehabilitation centers self-sufficient. In order to obtain this goal of self-support, all of the centers have developed methods of earning revenue. This has ranged from selling their agricultural products and crafts to participating in small construction projects. A unique enterprising project initiated by one center was the development of a guest house within the city that is adjacent to the rehabilitation center. This small hotel can house six guests, and is entirely operated by the inmates (Phase 4) from the center. It is felt that such business ventures will help defray some of the operating costs of rehabilitation centers. However, the author found that the highest proportion that a center has been able to contribute to its operating costs was 35%. In order to combat the high recidivism rates among drug abusers and to foster community transition, the government developed a system of aftercare houses in 1987. Presently, there are 36 aftercare houses in the country, and the goal is to have 66 of these facilities in operation by 1992. Each aftercare house is administered by a rehabilitation center, and the residents are persons who are in Phase 4 of their treatment program or have just been discharged. The aftercare houses are similar to the halfway houses in the United States, and are not as regimented as the rehabilitation centers. Admittance to an aftercare house is based on the recommendation of the director of the rehabilitation center. The average length-of-stay for a resident is usually 8 months, but there is really no time limit on how long a person can live at the facility. Discharge from the aftercare house is voluntary, and occurs when the resident feels that he or she is ready to make the transition to the community. While living in an aftercare house, the resident receives counseling services and is involved in a variety of work programs. Besides fostering community transition, another aim of the aftercare houses is to supplement the difficult task of monitoring the two year aftercare supervision that is required of all persons who are discharged from the rehabilitation centers. Presently, the average caseload of an aftercare officer is 200, and this probably accounts for why the government loses contact with close to 40% of those inmates who have been discharged from the rehabilitation centers (Anti-Dadah Task Force, 1989). PREVENTIVE
DRUG EDUCATION
Preventive drug education in Malaysia involves the governmental Ministries of Education, Information, and Youth and Sports. These ministries attempt to increase public awareness of the dangers and conse-
quences of drug addiction (Anti-Dadah Task Force, 1989). Since 1984, preventive drug education programs have been implemented in the public schools, community, and work place. Drug abuse does not appear to be a problem in Malaysia’s public schools. In 1989, only 2% of the registered drug abusers were public school students (AntiDadah Task Force, 1989). Drug prevention education in the primary and secondary schools is integrated within courses that focus on health promotion, and in a variety of co-curriculum activities. Health promotion in the schools integrate drug prevention education in courses that deal with personal hygiene, living skills, citizenship, and the development of positive family and interpersonal relationships (Foong, Maznah, Navaratnam, &Kong, 1986; Ministry of Education, 1987). There are numerous co-curriculum activities that deal with drug prevention, and those activities that have been implemented within the last 3 years are as follows: Peer counseling program. The program, which began in 1988, involves a 5-day training session for students who have been identified by their headmasters and teachers as potential leaders. Student colloquia. In 1988, two workshops for secondary students were held. The workshops emphasized interpersonal skills development, and the participants were given the opportunity to discuss the drug problems encountered by students in their schools and effective preventive strategies. The colloquia have been expanded and are held every year. Antidntg badge scheme. The program began in 1988 and involves all the uniformed organizations (i.e., boy scouts) in the country. Within the last two years, 96 students received badges for a wide variety of antidrug activities. Holiday work camps. Because there are a large number of abusers who have dropped out of school, the Ministry of Youth and Sports conducts holiday work camps during the school breaks. These camps are composed of school children who are viewed by their teachers as being at high risk for dropping out of school (poor grades and behavior). There were 16 one-week camps held in 1988, involving 1,600 students. The stated purpose of these camps is to develop the self-confidence of these children by strengthening their national and spiritual values. In addition to these co-curriculum activities, a random urine testing program has been introduced into the secondary schools. This program began in 1988, with 60 schools being screened. Presently, random urine testing involves all the secondary schools and occurs twice a year. It is also important to note that random urine testing is required of all government employees, civil service job applicants, and recipients of grant awards. The community-based preventive drug education programs are directed at government officials and cit-
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Has Malaysia% Antidrug Effort Been Effective?
izens at the local level. For the most part, these programs have consisted of in-service training on the methods of disseminating information about drug abuse to the public and a variety of publicity activities that focus on drug abuse prevention. The country’s major voluntary organization, called Pemadam, is most clearly identified with these community activities. The organization was formed in 1976, and although private, Pemadam is closely associated with the government (the prime minister has the responsibility of appointing the national president). Pemadam works with all the religious, social, and welfare groups, civic organizations, and private industry. Some of its many preventive drug education functions include the dissemination of cassette tapes, films, and brochures; the organization of seminars, mobile exhibits, and competitions with antidrug themes (i.e., poster, song contests, etc.); and the operation of aftercare camps. A relatively new development in Malaysia’s preventive effort occurred in 1987, with the initiation of a program called, Concentrated and Integrated Projects. This government project categorized various areas in the country as either “black” or “white” based on the severity of the drug problem in the region. If an area is targeted as “black,” all preventive drug education and enforcement activities are intensified. In order to strengthen the dissemination of information about drug abuse, a program for training key communicators was developed in 1988. In this program, formerly drug-addicted individuals who have recovered are trained as public speakers and are sent to local community and school functions to discuss their views about the prevention of drug abuse. In 1989, two of these key communicators formed a self-help group similar to Narcotics Anonymous, and the group has grown from 3 to 30 members. In 1987, a training program in drug abuse counseling was developed for all governmental agencies. The goals of the program were to increase the knowledge and awareness of senior personnel managers on the drug situation in the country and to provide them with a basic understanding of counseling to enable them to detect and help their colleagues and staff who may be involved in drug abuse. The first course was given to 28 managers, and this was followed by six similar training courses for personnel managers from both government agencies and the private sector. Finally, in order to consolidate all financial contributions made by companies, institutions, and individuals to drug abuse prevention, an antinarcotics trust account was formed in 1987. This fund is managed by the prime minister’s department, and the tax-exempt monies have been used for the drug abuse prevention colloquia for secondary students, for production of a video tape describing the country’s antidrug initiative, and for the publication of a drug abuse prevention
manual for employers in the private sector (AntiDadah Task Force, 1989). DISCUSSION
From the information gathered in this follow-up study, it is difficult to make any definite conclusions concerning the success of Malaysia’s antidrug strategy. However, there does appear to be some trends which would merit discussion. First of all, even if one takes into account the large increase in the number of drug abusers in 1988, there does appear to be sufficient evidence of a decline in the number of Malaysians detected for drug abuse. In the same manner, the contention that the incidence of drug abuse has plateaued also seems to be valid. Although this trend is very encouraging, the high recidivism rates are not. In fact, it appears that as Malaysia’s drug rehabilitation programs expand, so does the relapse rate of drug abuse. This “revolving door” syndrome in the treatment of the drug-addicted individual in general has been welldocumented (Miller & Hester, 1988; Sobell & Sobell, 1980) and is evident in the Malaysian antidrug effort. The official government explanation for the high recidivism is that it is due to the lack of rehabilitation facilities and aftercare workers. This explanation can be supported by the large number of rehabilitation centers that are over capacity, as well as the large caseloads of the aftercare workers. As a result of this situation, the government continues to open more rehabilitation centers and aftercare houses. Another factor that may be related to the high relapse rate among drug abusers is simply that the country’s rehabilitation system is not effective. Malaysia has committed itself to the therapeutic community treatment concept, and it is possible that this approach may not be suitable for all drug abusers. That is, there are no methadone treatment or hospital programs for drug addicted individuals in Malaysia. However, there really is no clear evidence that one drug treatment approach is any better or worse then another (Miller & Hester, 1988; U.S. Department of Health and Human Services, 1981). Even though Malaysia has not relinquished its treatment model, many professionals feel that their treatment effort is being hindered by grouping all types of drug abusers in the same facility (Haji Shariff Osman, 1990). That is, it is felt that “hard core” addicted individuals can have a detrimental effect on those persons who have entered a rehabilitation center for first time. Therefore, there has been a recommendation for segregating rehabilitation center inmates based on their previous history of drug abuse (Haji Shariff Osman, 1990). In the same manner, there has even been a proposal to separate the “hard core” addicted individual from society for the rest of his or her life (Mohamed Zaini Rahman, personal
176
communication, July 13, 1990). Briefly, the proposal involved the development of a self-sufficient community that would be composed of only these drug abusers and their families. With some thought, this suggestion is similar to the philosophy of Synannon when it was first founded (Deissler, 1970). The last explanation that may explain Malaysia’s high recidivism rates pertain to the nature of drug addiction itself. It is a commonly held belief that drug addiction is a disease that has no cure and can only be controlled. As a result, relapse is to be expected and is part of the recovery process. Malaysia has rejected the disease concept of addiction and views drug addiction as social deviancy. Furthermore, the length of time that a person says he or she has been drug free before a relapse occurs is not tabulated by the National Drug Information System. Therefore, it appears that the length of time that a person has remained drug free is not a significant factor in Malaysia’s treatment philosophy. Instead, rehabilitation success seems to be based on lifetime abstinence from drugs. Because of the high recidivism rates for drug abuse, it is difficult to state that Malaysia’s rehabilitation programs have been effective. In fact, one could make the argument that the observed decline in the incidence of drug abuse is the result of the country’s strong law enforcement and/or preventive education efforts. Similarly, Malaysia’s 7-year battle against drug abuse raises further questions about the validity of the common belief that a massive effort in law enforcement, preventive education, and rehabilitation will result in the elimination of a country’s drug problem. This is especially applicable as one reviews the antidrug strategies put forth by former President Reagan and President Bush. Even taking into account the politicalcultural differences of both countries, there are many components of the Malaysian system that have been proposed or implemented in the American effort, including such things as a death penalty for traffickers and the use of paramilitary training in treatment. In fact, the major criticism of the American omnibus antidrug bill has been the over-emphasis placed on law
J. F. Scorzelli
enforcement and the lack of funding for drug treatment programs. However, even though the Malaysian rehabilitation effort has received unrestricted government funding, there is still no indication that it has been successful. REFERENCES Anti-Dadah Task Force. (1989). Luporan dud&r (drug report). Kuala Lumpur, Malaysia: Author. Deissler, K. (1970). Synannon: Its concept and methods. Drug Dependence, 5, 28-35. Deva, M.P. (1988, November). The missing link in drug dependence prevention in Muluysiu. Paper presented at the 10th INFGG Conference: From Global Commitment to Community Action, Kuala Lumpur, Malaysia. Foong, C.P., Maznah, I., Navaratnam, V., SCKong, H.S. (1986). A comparative study of the psychosocial profile of drug using and non-drug using school children. Pinang, Malaysia: National Drug Research Center, University of Science, Malaysia. Haji Kamaruddin bin Ngah. (1984, December). Satu masulah yang penuh dengan cabaran (Results of treatment). Paper presented at the conference, Kaunselin Dalam Pemulihan Dadah (Counseling With Drug Addicts), Bangi, Malaysia. Haji Shariff Osman. (1990, July). Dangerous mix. Paper presented at the National Drug Treatment and Rehabilitation Seminar, Kuala Lumpur, Malaysia. Miller, W.R., &Hester, R.K. (1988). The effectiveness of alcoholism treatment: What research reveals. In W.R. Miller & R.K. Hester (Eds.), Treating addictive behaviors: Processes of change (pp. 121-174). New York: Plenum Press. Ministry of Education. (1987). Drugprevention educationprograms in Malaysian school system. Kuala Lumpur, Malaysia: Author. Scorzelli, J.F. (1988). Assessing the effectiveness of Malaysia’s drug prevention education and rehabilitation programs. Journal of Substance Abuse Treatment, 5, 253-262. Sobell, L.C., & Sobell, M.B. (1980). Convergent validity: An approach to increasing confidence in treatment outcome conclusions with alcohol and drug abusers. In I.C. Sobell, M.B. Sobell, and E. Ward (Eds.), Evaluating alcohol and drug abuse treatment effectiveness: Recent advances (pp. 177-183). New York: Pergamon Press. U.S. Department of Health of Human Services. (1981). Comparutive effectiveness of drug abuse treatment modalities (DHHS Publication No. 81-1067). Washington, DC: U.S. Government Printing Office. Walsh, W.D. (1981). Importance of Iraqi-Iranian conflict. Drug Enforcement, 8, 7-12.
