Road to poverty

About 35 years ago, in an era when India did not even talk about alcoholism and when alcoholics were treated by psychiatrists, Shanthi Ranganathan, a non-medical person, began her journey to build a place that looked after and turned around alcoholics and drug addicts. Hers was an emotional decision after she lost her husband, T.T. Ranganathan, to alcohol. Her determination and the unstinted support from the family saw her establish a pioneering facility in India to treat alcoholics and drug addicts, the T.T. Ranganathan Clinical Research Foundation, popularly known as the TTK Hospital. “I started without thinking too much. If I thought too much about it, I would have joined [the company] TTK,” she said in an interview to Frontline . “For me, the pain was too much. Alcoholics are not bad people. They are seen as bad people; immoral people. They are good people, they do not know how to get out of their illness... I wanted to do something for them.” In this conversation, she shares her experience in treating patients, and what more needs to be done.

Have activists given up on the possibility of prohibition being made state policy? The main justification of the government on why it retails alcohol on its own is that the consumption of spurious alcohol and deaths in hooch tragedies have come down.

I will not say that illicit use of alcohol will grow a lot because it is not available legally. Only a very small percentage of people go for illicit alcohol.... That is not the real issue. Drinking once in a way is not an issue. Not all drinkers become alcoholics. Only a small percentage become addicted to alcohol. The signature pattern of drinking in India is you drink to get drunk. You see it everywhere. They may not drink for 20 days a month, they get drunk on one or two days of the month. This is the one [day] that will create a lot of consequences. Drinking and driving, getting into violence, fighting with people....

The violence that you refer to here, is it on the streets or is it domestic violence?

It is everywhere. Every day there’s a death [as a result of alcohol-related violence]. Domestic violence is also a major issue. A sober man normally will not touch his wife [with the intention of harming her]… unless he is under the influence of alcohol. We work in villages. Almost 70-80 per cent of alcoholics whom we treat are abusive, both verbally and physically, when they are under the influence [of liquor]. The next morning, the alcoholic person becomes a normal person. Why do you think the woman stays with him after all the abuse? Alcohol is definitely a major cause for violence.

When it comes to domestic violence, is it a phenomenon restricted to the lower socio-economic strata?

We see it [alcohol-induced domestic violence] in middle-class [families] too.

Are instances of alcohol-induced domestic violence growing?

It’s growing. There are two factors responsible for the violence. One is alcohol. The other is a co-occurring psychiatric disorder. A man who has a psychiatric problem, such as suspicion, paranoia—he can also be violent. But some consider the physical abuse as the only abuse. Verbal abuse, emotional abuse, treating the wife in a demeaning manner—all these are abuses, too. These forms of abuse cut across all economic strata.

How do you deal with co-morbidity in an alcoholic, especially when the disease is a psychiatric disorder?

We have to treat both concurrently. Many times what happens is that de-addiction centres miss this diagnosis [psychiatric illness]. It has to be diagnosed and treated. Sometimes it so happens that a psychiatrist takes care of the mental disorder. But, unfortunately, the alcoholism is not dealt with. What happens as a result is that he [the patient] will be fine for a few days, but from the time he begins consuming alcohol, he may not take his psychiatric medicines.

Debt and alcohol seems another vicious cycle too...

Definitely. Today, a person has to spend a minimum of Rs.200 for legal alcohol. Once he is drunk, instead of going home in a bus, he might end up taking an autorickshaw. He might end up tipping the driver liberally. Imagine what happens if he drinks for 20 days a month. What happens if he does not go to work the next day? He will force his wife to part with money.

Is the average age of the drinker coming down?

It is definitely coming down. What we see is, the day they [students] complete the Class 10 or Class 12 examinations many youngsters go and drink. Maybe that’s the only day they drink. They have fun. The majority of these students stop [after the first time].

A few of them might continue. The reasoning will be: it has given me a lot of fun, it has given me a lot of enjoyment. Let me try it again. The initiation starts young. What we say is, push the initiation... you have to be able to recognise the consequences of your decisions, you have to be mature enough, emotionally... and this does not come before you are 21-22 years of age. If they start drinking at the age of 16 or 17 or 18, the chances of these kids becoming alcoholics are much higher. That’s the reason for the higher legal age for drinking. All of this has an impact.

Look at the WHO’s [World Health Organisation] global strategy to reduce the harmful use of alcohol. One thing they talk about repeatedly is the availability of alcohol. Don’t talk about prohibition; talk about the availability of alcohol. Many women [whom we work with] ask why the [retail liquor] shops open before 10 a.m. If they open after 10 a.m., most of the men would have gone for work. But when the shops open early, they don’t go for work. Working hours can be changed. And, Saturday is when a lot of labourers get their weekly pay. If the working hours of retail liquor vending units can be curtailed, it will help. In India, it is still not common to buy alcohol, stock it at home and then drink. It is only common among the higher strata of society.

The fortunate part in Tamil Nadu is that we [the government] have monopoly [over the retail liquor-vending business]. Monopoly has its own advantages. One decision by one person can change the scenario.... Regulate the retail sale of alcohol further and make sure the minimum age for consumption of alcohol is properly implemented. Adopt policies to stop sales to intoxicated persons. This is called server responsibility. It is there in Canada and many other countries. If you serve alcohol to an intoxicated person, in case of an accident you are liable.

What is the nature of the relationship between alcoholism and drug abuse? Are alcoholics also substance abusers?

Generally, adults who drink smoke. This is a preferred combination—alcohol and smoking. The youngsters, they are the ones who start with marijuana. Experimenting is not common among adults.... Youngsters are the ones who experiment various combinations.

Poverty, alcoholism and homelessness—is there a link between these?

In rural areas, if alcohol consumption comes down, you will see that the poverty will also come down. Both the man and the woman go to work, plus they get free rice and benefits.... Now the wage in agriculture or construction is pretty good, about Rs.300 to Rs.400. Where does the money go? Only for alcohol. Poverty is mainly caused by alcoholism. They are not homeless people. If they were not drinking, the amount of savings for each family will be very high.

We conduct camps in villages. The majority [of the participants] are from the lowest strata of society. When they adhere to our programme, you will see an amazing improvement in the standard of living. At the end of one year, you will find that they would have bought two-three sovereigns [of gold], they would have renovated their house... we cannot even think on those lines because for us so many expenditures, such as house rent, is standard. It’s not there for them. We assess them at the end of a year. The greatest achievement is that they are regular at work, [there is] economic improvement, and [domestic] violence stops completely.

Is there a correlation between alcoholism and suicide? What has been your experience?

Yes. If the man [in a household] commits suicide, there have been many cases where the woman also commits suicide because of the pressure [from society]. It happens to the user [the alcoholic] as well as the person who lives with the alcoholic. There are instances where the woman commits suicide because the man would have insulted or abused or beaten her in front of the immediate community. These are impulsive decisions. They do not think. There are also many cases of attempted suicide.

What is the philosophy behind your interventions among alcohol users?

We are mainly worried about hazardous drinking. People who drink and drive. People who drink and get into other issues such as violence; people who develop medical problems. So we are looking at people who misuse alcohol. The focus should be on reducing the harm. We cannot look for prohibition as a solution. It is never going to happen.

Over the years, the TTK Hospital would have treated over 25,000 addicts. What is the relapse rate?

It is a disease prone to relapse. Let’s accept that. Relapse is not the end of the treatment. When a relapse happens to an individual, we immediately get him admitted. Initially, when we started, we were reluctant to talk about relapse.... Now when we have a relapse, we call it “lapse”. We encourage the person to come back. Our advice is, “do not allow it to happen again”. We do not ask any questions. We keep him in the relapse ward for three days, put him on Disulfiram [a pharmaceutical drug] and send him back. We also have a five-day programme that addresses questions such as “What do you do when there’s a relapse? What are the symptoms? How do I deal with it? How do you prevent relapse?” Definitely patients relapse.... But only about 20 per cent of our patients lose touch with us. Rest of the relapse cases come back.

What is the role of the caregiver in the treatment process? Is the caregiver the most important person in the programme, or is it a combination of the caregiver, the hospital and an organisation of those who have turned sober, such as Alcoholics Anonymous (AA)?

Generally, we say that the individual is responsible for his recovery. The wife [who, in most cases, is the primary caregiver] comes here to empower herself. Because she has been destroyed by his alcoholism, she cannot take care of herself, she might have quit her work because she’s not able to concentrate, she cannot cook for the children, she even thinks of committing suicide.... She can cook for him and the children, but she should not be feeding him. We tell her, don’t take the blame for his drinking; you are not responsible. You are not making him drink. He is responsible. He has to come for follow-up, he has to take the medication. AA wants to help such people, but it is only a support centre. If you do not turn up at the AA, there’s nothing the AA can do.

In your experience, what are the hurdles to the recovery of a patient?

If there is no support group, recovery can be a problem. If there is no family support, in the sense that if he is living alone, there is a problem. A lot of people live alone, working in faraway cities, and live with people who drink. There’s a problem straightaway.

Under what circumstances do people get addicted? What pushes them down that rabbit hole?

The genetic factor is responsible. Many studies have been done.... Nobody wants to become an alcoholic. All of them want to enjoy a drink but [the moment some of them begin drinking] it’s beyond them.