Five years later, Inez Feria still remembers the line snaking around the block outside the clinic in Cebu City. Men and women were smiling and laughing as they queued for clean hypodermic needles. For Feria, an advocate for the rights of drug users, it felt like a hopeful moment.
The needle exchange — part of an international push to slow the region’s skyrocketing HIV transmission rate — was the largest of its kind in the Philippines. When it started in 2014, about half the city’s drug-using population (approximately 6,000 people) was HIV-positive, and three-quarters of those people contracted the virus after sharing contaminated needles. By almost every metric, the pilot program exceeded its targets: fewer drug users reported sharing needles, more were being tested for HIV and all could access basic medical services.
But only months after the clinic was up and running, the Cebu City Anti-Drug Abuse Council filed an official letter demanding that it be shut down. In April 2015, five months into the planned two-year program, the clinic’s syringe distribution was suspended due to “political pressure,” according to the American medical non-profit Population Services International (PSI), which started the program.
A few weeks later, Philippine Senator Vicente Sotto gave a speech condemning the service. “Harm reduction strategy is, in reality, a pro-illegal drugs strategy,” he declared. “This nonsense must stop.” Needle distribution at the clinic permanently halted, and, according to a PSI review, “multiple clients were lost to follow up,” while new referrals slowed to a trickle.
“It was really sad,” Feria said. “It wasn’t just about providing syringes. It had a bunch of different services, HIV testing, counseling. People got connected to all these services that they otherwise wouldn’t have. It showed that people do want to take care of themselves.”
Harm reduction — a treatment method highly regarded as effective for improving health outcomes for people addicted to drugs — remains controversial in the Philippines. As FRONTLINE’s documentary On the President’s Orders depicts, Rodrigo Duterte has waged a deadly campaign against drugs that has led to a deep stigma for drug users and few effective resources recovery in the Philippines.
So often, Filipinos struggling with drug addiction are forced into an uncomfortable, untenable corner: seek treatment in packed or expensive zero-tolerance facilities, or keep using and risk going to jail or — as many in the Philippines allege — being killed by the police.
Yet Feria and other harm reduction advocates see an alternative path.
Like most Filipinos, Feria grew up hearing that drugs should be avoided at all costs. But when someone close to her started using, she began looking into treatment options. She was shocked at the poor quality of what was available, calling it “pejorative, infantilizing and disrespectful.” There had to be a better way, she thought.
In 2000, after seeking help from two American harm reduction experts, Fred Rotgers and Andrew Tatarksy, Feria started her own residential treatment facility. Back then, family members were often confused that Feria didn’t employ crews of burly men to forcibly take drug users off the streets, a technique that is still widely used.
“We would ask, ‘What makes you think that you need that?’” Feria said. “People would ask, ‘Why do you have no isolation rooms? Why do you have no barbed wire?’”
And still, community members often approached her, cautiously excited about Feria’s holistic path that focused on human connections rather than punitive measures.
She expanded in 2014, founding NoBox Transitions, a small, eight-person non-profit that lobbies, researches and organizes workshops promoting the approach and the skills it can teach — for instance, meditation techniques to help control cravings, or learning how to disinfect needles.
Harm reduction, Feria stresses, can be practiced within other treatments, including abstinence-only programs that are popular in the Philippines. (However, many Philippine drug recovery providers, including one program manager contacted for this story, are unfamiliar with harm reduction and refuse to work with NoBox.)
Phelim Kine, director of research and investigations at Physicians for Human Rights, said that NoBox is doing innovative work in a place where even having a hypodermic syringe is a crime.
“The anti-narcotics law is so draconian… It was problematic before, but it’s murderously so now,” said Kine, a former deputy director of Human Rights Watch’s Asia division. “Anyone involved is putting themselves at risk because they’re dealing with ‘drug dealers,’” he told FRONTLINE. “[Duterte’s] campaign is premised on the fact that these are evil people.”
Months before Duterte was elected, it seemed like NoBox’s efforts might pay off in a big way. NoBox and other advocates came close to establishing harm reduction as a cornerstone of the country’s health care policy. Coordinated by Feria and her group, Tatarsky joined in on planning calls — which included high-ranking government officials — from his office in New York.
“It was mind-blowing that there was such a strong reception, and it felt very promising,” said Tatarsky. “We started to talk about how we would identify key people in various government agencies to train. But then Duterte was elected and that stopped the whole process.”
Instead of giving up after Duterte’s election, NoBox doubled down. Feria and her team continued to bring groups of people —students, families of addicts, religious groups and politicians — together. They were even joined by a prominent official from the country’s national Dangerous Drugs Board.
Still, the group faced significant challenges as Duterte’s anti-drug campaign ramped up. Under Duterte’s policies, police forces were expected to make long lists of confirmed or suspected drug users, who were then told to turn themselves into mandatory “rehabilitation” facilities. Local regional governments often didn’t have the training to deal with a sudden influx of hundreds, and sometimes thousands, of incarcerated drug users.
“There were no programs before. Nothing existed. Then, suddenly, they’re mandated to come up with programs. What are they going to do? They thought drug use was bad, so people who use drugs must be taken care of, punished,” Feria said. “A lot of the work we’re doing is in these workshops, where we can have a more nuanced conversation, unpack these things.”
Raffy Lerma is a news photographer and photojournalist who has spent the past three years documenting the human cost of Duterte’s drug war. He frequently appears on panels alongside Feria and exhibitions of his work and said NoBox has championed a necessary conversation.
“Every time I talk about this situation, and I show all my pictures, there comes a point where people are so down,” he said. “They don’t know what to do anymore. They always ask me, ‘What are the solutions?’” NoBox, he said, has provided hope for so many families — and healthcare workers — who are simply trying to do their best.
“People don’t know the options,” he said. “I hope the government listens.”
In a sign NoBox’s message is being heard, another hopeful signal has recently come from government. Two bills carried forward from the last Philippine Congress could reach a committee hearing phase during the country’s upcoming congressional session and jumpstart treatment of drug addicts with harm reduction approaches within its health care system — not only its penal system.
When she first visited the Cebu City clinic, Feria caught a glimpse of a future she believes in, one in which drug users are seen as complex and nuanced, often traumatized but not beyond help or care. Despite everything that has happened, and the fact that thousands of marginalized addicts are still being held in cramped, dangerous facilities, she still believes in a hopeful future for drug policy in the Philippines.
“We ask people, ‘What are some of the things you consider risky? Cooking? Driving? Crossing the street? Of course everybody has done something risky. But because we are informed we know how to minimize our risks and harms,” Feria said. “People tend not to hear themselves because of this loud narrative that drug users are bad. We need to make our narrative louder.”