Today's emphasis is on prevention of drug abuse, rather than its cure. But despite advances in anti-drug education, too many people still become hooked on narcotics. What does Taiwan do for the people who said yes to drugs?
"Two shots! Only two shots, and I was hooked," says Wu, 38, a gangster, describing how he became addicted to heroin. Out of curiosity, he started using the drug fifteen years ago, and it was not long before he found himself spending NT$20,000 (US$730) a day on dope. Two spells of imprisonment totaling six years did nothing to help him quit. When he came out he invariably returned to his underworld haunts, and to the heroin and amphetamines that would not be denied.
About a year ago, Wu discovered that his long-standing drug habit had damaged his brain, and the condition was getting worse. "I saw things that weren't there, heard voices, and became very violent," he recalls. "Basically, I was no longer capable of distinguishing between fact and fantasy." In a last-ditch effort to help him, Wu's family carted him off to the Taipei City Psychiatric Center.
The center's rehab program has three stages: physical detoxifi cation, psychological counseling, and social reintegration. If it is necessary to hospitalize the patient for detoxification, medicine will be given to ease the initial withdrawal symptoms, which usually last one to two weeks. Patients may leave the hospital once the symptoms subside, but they have to report regularly to outpatient services, where they receive counseling and must submit to periodic urine tests. Religious groups provide spiritual assistance to those who request it.
Wu has now made it through to the third stage, and is very proud of the fact that he has stayed off drugs for a whole year. It is difficult to determine the precise time at which a given addict is cured of his addiction, but the center adopts a rule of thumb which says that a patient who has not touched drugs for twelve months is unlikely to take them again. "I'm one of the very few people who's managed to quit the 'water way,'" Wu says. [The water way is slang for drug-taking by injection.] "For most people u sing the needle, death's the only way out."
Islandwide, the Department of Health (DOH) has authorized operation of similar programs at 129 hospitals and clinics, of which 44 provide in-patient treatment. These establishments play the leading role in Taiwan's rehabilitation efforts. "Enforcement can cut down supply, but it can't cut it off, so we need education and rehabilitation to reduce demand," says Tai Chuan-wan (戴傳文), section chief at the DOH's Bureau of Medical Affairs. In the absence of a centralized narcotics agency, this necessarily involves a division of responsibility. While the Ministry of Justice (MOJ) is the principal agency in charge of enforcement, the Ministry of Education is primarily responsible for anti-drug-education programs, and the DOH for rehabilitation.
When devising a program that would genuinely help addicts to quit, the first problem officials ran up against was that existing laws and regulations actually militated against what they were trying to do. In Ta iwan, drug abuse is a crime, and it followed that hospitals were obliged to notify the law enforcement authorities whenever an addict came to them for help. This naturally acted as a powerful deterrent to addicts who required medical assistance. The DOH therefore announced that as of January 1995, hospitals were free to treat drug abusers without reporting them to the authorities. But a much more fundamental change is on the horizon. A new narcotics control law has now passed its second reading in the legislature. Once it becomes law, drug addicts will still be classified as criminals, but rehabilitation will replace imprisonment.
But the reforms do not stop with removal of legal obstacles. Rehabilitation facilities and manpower are also being strengthened. "Taiwan's drug problem started to get serious in a very short period of time, beginning in the early 1990s--so short that existing facilities and manpower quickly became overstretched," Tai Chuan-wan says. "To provide enough effectiv e rehabilitation services, we really have to expedite improvements in rehab hardware and software." Over the past three years, the DOH has given more than NT$43 million (US$1.56 million) to designated hospitals to upgrade their addiction treatment facilities. In every one of those years, NT$6 million (US$218,180) was spent on educating rehabilitation staff and sponsoring relevant research.
One important educational project involves adding a rehabilitation module to the DOH's annual continuing training course for medical personnel who deal with mental illness. By the end of 1996, over 2,200 psychiatrists, nurses, and social workers had received such ongoing training. In addition, three rehabilitation training centers were set up in northern, central, and southern Taiwan, and these have also trained more than 2,000 professional people.
Moreover, rehabilitation research projects are now being conducted with an eye to both medical and social aspects. A major current project involves research i nto Naltrexone, which is undergoing trials at two of the island's hospitals. The medicine is an opiate receptor antagonist that negates the euphoria generated by narcotics. The theory is that when the anticipated "high" no longer materializes, attraction and dependency will both disappear.
Through its various research projects, the DOH hopes to develop a local rehab "pattern." "Drug abuse has social and cultural causes, as well as physical and psychological ones," says Lin Shih-ku (林式穀), chief of the Taipei City Psychiatric Center's Department of Addiction Science. "We are now mostly copying foreign rehabilitation patterns. But to take account of different cultural and social backgrounds, we have to develop our own particular model that will best help local addicts." When questioned about what that model is likely to be, however, health officials can only reply in vague terms.
DOH statistics show that in 1996, rehab outpatient services islandwide logged 27,484 pa tient visits, with a corresponding figure of 1,590 patient visits involving hospitalized treatment. These addicts sought help for many different reasons. Some were self-motivated, some were brought in by their families, and some came out of sheer desperation, unable to cope with the pain of dope deprivation. But compared to Taiwan's estimated 200,000-strong addict population, only a small fraction have so far asked for assistance.
One reason for this is that although the legal and technical obstacles to rehabilitation are being dismantled, lack of money keeps many addicts away. The Taipei City Psychiatric Center provides a good example. Fees for hospitalization total about NT$25,000 (US$910), per patient per week, and outpatient services, including psychological therapy and urine tests, cost approximately NT$5,000 (US$182) a patient per month. These fees are not covered by insurance, not even the National Health Insurance Program. Although this may look pretty small beer compared to what an addict has to spend on drugs, it is still beyond the reach of most addicts, who tend to spend every cent they have on dope.
Asking addicts to pay for rehabilitation is of course a reflection of society's attitude toward them. Tai Chuan-wan explains that while addiction is scientifically a disease, most people in Taiwan still perceive it from a moral point of view. "For most people, including many medical personnel, drug addicts suffer from serious moral defects and are criminals rather than patients," he says. "The general public can see no valid reason for sharing its national insurance benefits with crooks."
Whether patients or criminals, all addicts are aware of the damage that drugs can do to their health. Many of them are anxious to quit, but few of them make it through hospital rehabilitation programs. Currently, hospitals set an arbitrary cut-off point of between one and three years from the patient's first submitting to treatment when determining whether first-stage rehabilita tion has been successful. If a patient steers clear of drugs during the set period, he is considered to have been rehabilitated. The success rate is estimated by the DOH to hover around 20 percent, about the same as in most other countries with drug problems--hardly surprising, because the problems addicts face are universal.
"Physical detoxification is relatively easy," Lin Shih-ku says. "The hard part is knowing how to help addicts get rid of their psychological dependency on drugs and return them to society." Lin explains that psychological dependency is difficult to shake off, because addicts use drugs to escape reality and stress. Whenever they encounter difficulty or face pressure, they go back to drugs. In Lin's department, some addicts have become regular patients who show up for detoxification about once a month and go back to drugs afterward. "You can put them behind bars for several years," he says. "But many of them return to drugs as soon as they come ou t." Statistics show that more than 50 percent of Taiwan's 40,000 odd prison inmates are drug offenders, and more than half of these are recidivists.
This is a discouraging statistic, one that reflects on Taiwan's penal system as well as its efforts on the rehabilitation front. In an effort to improve matters, in the fall of 1993 the MOJ designated Tainan's Mingte prison an experimental rehabilitation correctional facility. Mingte is very different from ordinary prisons. Log cabins and trees take the place of concrete cells and electric fences. The tattoos on inmates' bodies are the same as those seen in other prisons, but the easy and relaxed atmosphere is unique. Watching inmates hard at work in the fields makes visitors feel as if they were at a tourist farm rather than a jail. "An open environment helps open their minds," explains Hsu Ching-yuan (許清原), the prison's warden. "With an open-minded attitude to life, their chances of going back to drugs is that much smaller."
Religious instruction and counseling is available to any prisoner who requests it. All of them do. Of Mingte's 230 inmates, 89 are in the Christian class, while the other 141 study Buddhism. Since they no longer suffer from physical addiction, the focus here is on helping inmates quit their psychological dependency and then return to society. To achieve this, most of them spend their days pursuing religious studies and doing physical labor. "Religion gives them the right attitude toward life and physical labor restores their health," Hsu says. "Once they have the right attitude, they don't need to rely on drugs to escape from reality. And when they get their health back, they are capable of returning to normal work."
To help inmates master skills that will enable them to make a living, or sometimes just to encourage them to develop an interest in healthy hobbies, Mingte also provides courses on cooking, brickwork, music, and art. Inmate 4624 in the cooking class says that he is not l earning a skill so that he can make a living, but merely enjoying something that may one day help enrich his life. "Addiction totally destroyed my family life," he says. "Maybe I do this because I want to make up part of the loss. It just makes me happy to think that someday I'll be able to cook for my family."
For similar reasons, most inmates appreciate these classes very much. "They've shown great interest and enthusiasm," says Chang Kun-huang (張坤煌), a master chef at a Tainan restaurant who teaches the cooking class. "As far as I'm concerned, they're as good as, or even better than, most of the people I've taught."
In determining whether its programs have been successful, Mingte sets a cut-off point of three years from release. If an ex-inmate does not take drugs during that period, that counts as a success. It is therefore still too early to evaluate the program's success-rate. Hsu points out that whether an addict is able to quit depends a lot on home environment and relationships, as well as family support and religious faith. "Most addicts start using drugs out of curiosity, and get their first dose from friends," he says. "If they go back to those people when they get out, it's more likely that they will use drugs again, and all the time spent and pain suffered during rehabilitation will have been in vain."
For this reason, unlike ordinary prisons that regard discharge as the end of their responsibilities, Mingte tries to keep in touch with former inmates through their families and sometimes through religious groups. But since the release of its first inmate in January 1995, 228 people have left the prison, and it has not proved possible to keep track of them all. Hsu admits that up to now, seven former inmates have been caught using drugs again.
The major difference between Mingte and appointed rehabilitation hospitals, of course, is that prison inmates may not come and go as they please. But in many respects, the two insti tutions do resemble each other. For one thing, they rely on religion or counseling as major resources when helping addicts get over their dependency on drugs and establish new social relationships. Beside working with prisons and hospitals, some religious groups also operate their own rehabilitation centers where religion is the only medicine used in both physical and psychological rehabilitation. Their success rate runs at about 20 percent, the same as that estimated by hospitals with detox and rehab programs.
Taiwan's domestic drug problem is not as serious as in many developed countries--at least, not yet. The government recognizes that prevention is the best way to go, and has made great advances in drug-related education. Law enforcement has also been strengthened recently. But Taiwan is discovering, as many countries have discovered before it, that once the damage has been done it is extremely difficult to reclaim the lost souls. Perhaps the hardest task that lies ahead is changing mindsets in s uch a way that all sections of society, particularly the medical establishment, come to view addiction as a painful misfortune, not a heinous crime. Rehabilitation, it seems, requires more than medicine and Moses to part the waves of the deep drug sea.