Punjab’s addiction anguish
The following is an edited extract from ‘Most of What You Know About Addiction is Wrong’ by Anirudh Kala, published by Speaking Tiger
IT is a myth that the people of Punjab have latched on to drugs only in recent years from previously having been ascetically abstinent. An Indian publication in 1928 noted that the Northeastern states and Punjab have a higher proportion of people ‘habitual’ to opium than the rest of India. Punjabis have always had an inherently contradictory attitude towards intoxicants. A benign tolerance has existed in uncomfortable juxtaposition with the predominant religion Sikhism’s censorious approach towards all intoxicants.
Although exact figures are available only for recent years, the tolerant attitude in Punjab towards alcohol and opium did not translate into large-scale runaway consumption. There are frequent references to amlis (addicts) and postis (people addicted to poppy husk) in early Punjabi literature and these are derogatory words. At the time of the Partition each village had a small number of people who took post or drank regularly. On the other hand, celebratory drinking was quite another thing and enjoyed social approval then as now.
As far as the typical profile of regular opium users in Punjab till the late 1980s is concerned, it was that of a well-functioning middle-aged farmer and the prevalence, as judged from anecdotal evidence, was moderate. Distinct from that was the specific and circumscribed common practice of giving farm workers opium husk during the backbreaking harvest season twice a year so that they would work tirelessly. This practice continues even now but to a lesser extent.
However, till the 1990s, psychiatrists saw very few cases of opioid addiction in the clinics because whatever people were doing was not considered addiction by society, by families and certainly not by them, although from all accounts it certainly was. Psychiatrists sensed, when patients were brought in for a psychiatric disorder which had nothing to do with opium addiction, that addiction was a problem. Routinely filled proforma of the detailed psychiatric history of every patient included questions about intake of intoxicants and fairly common opium use in men was an incidental finding. The proforma also included questions about family history of addiction, if any. And a good number of large rural extended families, which was the norm then, had at least one male member who had been taking opium regularly for years. But even if that person was sitting in the doctor’s clinic along with the patient, the psychiatrist could not have told him apart. And nobody else could have either. Punjab was then a state with a good number of high-functioning opium addicts. This was hardly a secret since there was no stigma involved.
Out of the people who took intoxicants, the middle classes and the well-to-do in the villages took pure opium, which came in the form of a dark gum; the poor in the villages took poppy husk as a light, coarse powder, brownish in colour, which was bulky but if taken in sufficient quantity over the course of the day delivered the same amount of opium to the user. The city people drank and that was all there was to it. The vast majority of people, of course, then as now, neither drank nor took any other intoxicant.
In the late 1980s, psychiatrists in Punjab started to see patients of drug addiction in their clinics in significant numbers, a trickle at first, it soon became a continuous flow. But these were not the usual heavy drinkers in their forties with liver problems or the moderately rich middle-aged farmers taking opium or even the poorer farmhands addicted to the bulkier bhukki.
Something was changing and changing fast. For one, addicts were becoming younger. Frightfully younger. Drugs were changing too. Those who were showing up at clinics were young men addicted to synthetic opioids like capsules of Dextropropoxyphene, nicknamed ‘proxy’, which was then commonly used as a pain reliever by surgeons and orthopaedic doctors for their trauma and post-surgery patients. The young men who were misusing these would buy them over the counter from chemists who were happy to oblige. Chemists’ shops had sprouted all over Punjab like mushrooms after a spell of rain and they were fully licensed by the government. They were of course required to sell these drugs only on prescription and keep a record, both of which they did not do.
When questioned by the press, the government pleaded a shortage of drug inspectors. Chemists’ shops were located in the cities, small towns and even on the narrow link roads which criss-cross the whole state. Even in remote places where you could not find a mechanic for miles if your scooter broke down, you could find a licensed chemist’s shop to buy enough capsules of proxy to keep you high for a month. Nobody has ever asked the Punjab government why thousands of licences for chemists’ shops were given when it was clear that the only way those many shops could have stayed afloat was by selling habit-forming medicines over the counter.
Opiates have been justifiably used for thousands of years as a highly effective treatment for cough and diarrhoea. Codeine, a natural opiate and a component of opium, has been a legitimate component of popular cough syrups like Corex for decades. Similarly, tablets of Diphenoxylate (brand name Lomotil), a synthetic opioid, has been used as an emergency drug to stop severe diarrhoea. All three drugs have an opium-like effect if taken in high doses. And the amounts ingested by these young men were very high. Two hundred tablets of Lomotil or forty capsules of Proxyvon, or ten bottles of hundred millilitre Corex syrup a day were the average intake by patients who were now coming to the clinics. And in many cases, instead of this OR that, it was this AND that.
That was the time when people setting out on morning walks started finding parks in the cities and towns of Punjab littered with empty bottles of cough syrup and used strips of proxy capsules, and the parents of young men began panicking at the sight of empty bottles found in the vicinity of their houses.
A rehabilitation session: Those showing up at clinics were young men addicted to synthetic opioids
A notable feature of the case histories as recorded in psychiatric clinics at that time was the occupation of the young patients. It often went like this:
‘What does he do?’
‘What was he doing earlier?’
If one probed further into the history of the patient the following would come to light: he was in school, an average enough student, a bit stubborn and quarrelsome but that profile fit in with the overall average at that age. He had then joined a college in a nearby town, either a degree course in humanities or more commonly a diploma in hospitality or in management. Bachelor in Business Administration (BBA) was a course commonly offered. Why? Because the parents were told this was a job-oriented course and at two lakh rupees, admission was cheap. And there were chances of going abroad, as the father would report. And why would he need a job? The family had land, nobody in the family had taken up a job before. The boy did not want to do farming because over the previous three generations, three brothers had had nine grandsons — forget the daughters because they are not counted in Punjab or anywhere else for that matter in North India for the purpose over three generations.
A study conducted at the Medical College, Faridkot in central Punjab and published in the Indian Journal of Psychiatry reported that between 1994 and 1998, the use of opium decreased in Punjab by approximately 40% while the use of the cheap substitute, poppy husk, increased by 55%. Over and above this the use of pharmaceutical opiates like proxy, Corex and Lomotil by youngsters, which were even cheaper and easily available doubled (Sachdeva et al, 2002). This simple observation was fraught with significance for anybody who observed the field of drug addiction in Punjab because behind those ordinary figures lay the lengthening shadow of social and economic changes plaguing the state, a slippery slope that has not levelled off till today. A short sketch of opioid intake in Punjab would approximately go like this, with a lot of overlapping and sub-regional variations:
Before 1985: Natural opioids. Mostly opium but also opium husk, colloquially called bhukki or dode — the poor man’s opium, cheap but bulkier quantities needed to be taken for same degree of effect. Supply of opium was from Afghanistan and Rajasthan and that of husk from Rajasthan where it was legally grown and available to people with addiction on permits.
1985-2000: The ratio starts changing in favour of cheaper husk and pharmaceutical opioids like Proxyvon, Corex and Lomotil.
2000-07: Pharmaceutical opioids predominate and also the demography of opioid addicts changes from men predominantly aged thirty to fifty years to younger men in their twenties.
2007-2012: Heroin, both the street form called smack and the pure form called chitta, becomes the predominant opioid addiction in Punjab, gradually phasing out pharmaceutical opioids as the government belatedly comes down hard on chemists.
Present: Heroin continues to be the most common opioid used by 80-90% of people with opioid addiction in Punjab.
The reason which drove this change from natural to semi-synthetic and synthetic opioids, not just in Punjab but eventually all over India and many other countries, lay in America and its so-called War on Drugs. This ‘war’ enforced total prohibition of all drugs including opioids across the world through international treaties sponsored by the West. The most visible and also the most harmful effect of prohibition is that it converts the intoxicants that are available to people from milder and bulkier to stronger and concentrated because the latter are less likely to be detected in transit and hence easier to smuggle.
That is why whenever and wherever there is prohibition of alcohol in the world, the only alcoholic beverages that are available are those with high alcohol content like whisky, gin and vodka. Smugglers find it difficult and riskier to smuggle in beer and beer drinkers are thus coaxed into drinking whisky or vodka available in the alleys, if they want to have that weekend drink. The conundrum of prohibition comes from the simple fact that it is easier to smuggle a van filled with whisky bottles than a truck full of beer bottles into a state with prohibition.
A public pledge in Amritsar: Mere policing hasn’t worked
While the international treaties that India was signatory to ban the production, trade and even use of all drugs obtained directly from any of the three plants, opium, cannabis and coca and their chemical analogues, Indian delegates to these UN conventions, to their credit, managed to salvage bhang from being banned, citing traditional and cultural reasons and the fact that bhang is commonly used during religious festivals. How bhang was exempted as a concession to countries like India is in itself interesting. Without mentioning bhang, the Single Convention on Narcotic Drugs, 1961, defined cannabis as follows:
‘Cannabis means the flowering or fruiting tops of the cannabis plant (excluding the seeds and leaves when not accompanied by the tops) from which the resin has not been extracted.’ Cannabis, thus defined, was what was banned by the UN convention. Since bhang is prepared from the leaves of the same plant, it was not banned, while ganja or marijuana, which is extracted from the flowering tops, was. As was charas, which comes from the resin.
This could have been a good way for India to promote a mild and internationally legal intoxicant, which could have been easily regulated and sold in government or private stores. Most Indian states, however, took the moral path and did not make use of the pragmatic concession which its experts had managed to extract from the international community, to provide a mild, cheap, relatively safe, and some would even say, the safest intoxicant, to people.
THE GREEN REVOLUTION
I met Narinder Kaur one August afternoon, when, despite the rain and the slush on the roads, her distraught husband brought her to my clinic on his motorcycle, all the way from their village located on the Doraha canal. She was in her early fifties and was having what appeared to be a panic attack. Her husband said she had never suffered from anything like this before. Her face was frozen with anxiety, her body so tremulous she had to be supported and she could not breathe easily. Talking clearly required effort on her part.
Her husband had no idea what was happening; the village GP had told them it appeared to be a psychological problem and had sent them to me. After I sent the husband out of the room, gave her a glass of water, and an anti-anxiety tablet to keep under her tongue, she settled down quickly. When I asked her if something specific had triggered the attack, she fished out a tiny polythene pouch filled with a brownish white powder from her kameez (loose tunic) pocket.
To me, it became clear what had happened. Narinder was yet another mother in Punjab who had discovered street heroin while emptying her son’s pockets before doing the laundry.
Mothers with young sons learnt from newspapers and television reports what a pouch of heroin looked like and prayed they would never have to see one in real life. She had not yet confided in her husband because he had unstable blood pressure and although she strongly suspected the white powder was what she feared, she was not completely sure yet. She told me later that there had been signs in her son’s behaviour all along that she failed to recognize. After spending half a day in the clinic, Narinder went home symptom-free and the focus shifted to her son, Navjot, who was brought to the clinic the next morning.
Young people joined new colleges whose degrees were not worth anything
Navjot, I was told, had initially refused to come. When his father confronted him with the pouch of heroin, he had shot back, ‘So what? You drink half a bottle of liquor every day, don’t you? I take this.’ After the outburst he had clung to his mother, cried, and apologized to his father and confessed he had started snorting smack six months back after he failed the IELTS examination. IELTS is the standard English examination those who want to go abroad on a study or immigration visa to English-speaking countries are required to take.
I had heard a lot about IELTS from my young patients, a good number of whom aspired to go to North America or the UK or Australia. In the past twenty years, on my way to work I have noticed that an IELTS coaching course is the most advertized product on the walls of the city, and this is true for the whole state of Punjab. The only large hoardings which have survived the economic slowdown are those of the IELTS coaching centres. It is difficult to find a young man/woman who does not want to go abroad for good. Narinder and her husband went on to reiterate before me what I had been hearing for years from other rural families.
Navjot’s grandfather owned thirty acres of land and theirs was a relatively prosperous family in not just their own village but even in the surrounding villages too. Navjot’s father had three brothers and each inherited seven and a half acres. His father and his elder brother farmed that land but, the holding being small, it was barely cost-effective. If Navjot wanted to do farming like every adult male in the family so far, he and his brother would have less than four acres each after their father passed away. Hence, the family’s plan for him to get a college degree and go to Canada made sense. In Scarborough, Canada, Narinder’s nephew was part owner of a petrol pump. Navjot could work at the pump till he got a better job. To pay for Navjot’s college admission and the advance the travel agent demanded, one acre of land in the small town across the canal was mortgaged to an arhtia, a commission agent, whom the family sold their farm produce to twice a year.
But as of then, both the university degree and the visa seemed to be beyond reach. As Navjot told his parents, even though he did get ready and leave the house every morning on his motorcycle to go to the university there was really no university to go to. He had been suspended for six months after a fight with another student a while ago. He was intoxicated when he had picked the fight. He had kept the expulsion a secret from his parents. Even before that he had been irritable for months, sleeping late and waking up late, dressing sloppily which alone should have made the parents suspicious, since he had been a rather natty dresser before.
That was three years back. Navjot was in and out of heroin addiction for the next two years but after he got a job, he has been clean for over a year. He could not go to Canada because although he did get a degree eventually, that degree was not recognized in Canada. He now works as a salesman at a shopping mall that has sprung up outside the city. He commutes from his village forty-five minutes each way daily because his salary is not enough for him to rent a room in the city. But the job has certainly been a turning point. The mooring of a routine and socializing with friends from work, including a young woman from the neighbouring village he has been seeing, have been crucial in keeping him out of trouble so far. As the saying goes, ‘the opposite of addiction is not sobriety but human connection’.
Equally vital is the treatment that has been continuing for three years although there were interruptions caused by relapses during the first two years. Navjot comes in for counselling and medication once in two weeks and makes it a point to say hello to me whenever he is here. He has even referred other patients, young men like him, to me.
Narinder never had a second panic attack and has been the emotional bulwark for her son. This is the main reason things have not been as bad with Navjot as they often are with other young men in a similar situation. Relatively speaking, Navjot’s is one of the feel-good stories. Most are not.
Any schoolboy will tell you that the capital of Punjab is Chandigarh but the truth is far more nuanced. Chandigarh is also the capital of the neighbouring state of Haryana while Chandigarh is neither in Punjab nor in Haryana, but a Union Territory governed by the central government. The capital of Punjab is outside Punjab! This freak arrangement has worked exceedingly well for the politicians and bureaucrats of Punjab. They get to live in a modern city as VIP guests without the headache of governing it. Chandigarh has some of the best colleges and the most advanced health care facilities in India, not to mention beautiful golf courses, a modern airport and three Shatabdi Expresses plying to Delhi in a day. Ironically, till 2011, Chandigarh had no rail connection to Punjab of which it is the capital. Unsurprisingly, hardly any senior politicians or senior officials of the Punjab government settle down in Punjab after retirement. Padma Bhushan Dr S.S. Johl is a rare exception. He is the most senior agricultural economist of the country, a former vice-chancellor of Punjab Agricultural University and of Punjab University, former chairperson of the Agriculture Price Commission of India, director of the Central Board of Governors of the Reserve Bank of India, consultant to the World Bank and the Food and Agriculture Organization of the UN and the current chancellor of Punjab Central University.
Small farmers became marginal and marginal farmers became labourers
Ninety-two-year-old Dr Johl talked to me on a winter morning, sitting in the sun-swept veranda of his modest house in Ludhiana. We discussed the golden days of farming in Punjab, what went wrong, the connections between the Green Revolution backtracking and addictions, and how it can all still be turned around.
The Green Revolution strategy succeeded in Punjab beyond the wildest expectations with production of grains increasing several times, especially of wheat and rice. A country plagued by chronic semi-famine became food surplus in a couple of years. The support by the central government by way of institutional mechanisms to ensure purchase of wheat and paddy at an assured minimum support price or MSP made all the difference. The system was both technology intensive and manpower intensive, the latter more so during harvesting season twice a year.
All of this happened because of the forward-looking entrepreneurial skills of Punjabis who were ready to take risks in trying out new methods. Another factor was the presence of a very large number of serving and retired armymen in Punjab, which ensured a minimum educational qualification and a comfort level in handling machinery of varying degrees of complexity and a willingness to experiment with those.
These initiatives made the rural economy of Punjab a model of economic development and prosperity. Labels like ‘granary of India’ and ‘India’s bread basket’ came in thick and fast. However, the new model was technology intensive and needed tractors, harvesters and other equipment. That required capital. Loans were available through banks owned by co-operative societies, but farmers were more comfortable with the arhtias with whom families had dealt for generations and who asked for very little paperwork. Soon, Punjab became the richest state in India with the highest per capita income in the country. The boom lasted for over three decades.
Over successive generations, with the breaking up of large joint families even in villages, land holdings became smaller till the size of the farms stopped being cost-effective for technology-driven farming. The average farm size in Punjab at present is eight acres and only one-third of farms are over twenty acres. The water table went down every year mainly because paddy is a water-guzzling crop and while canals in the areas provided a basic level of irrigation, the large quantity of extra water required during sowing and transplanting of paddy had to be pumped out from the earth. Traditional tube-wells no longer worked because of the dip in the water table. This required the powerful submersible pumps to be sunk in deeper and deeper, which was costly and required credit. The electricity supply in rural areas was erratic and so diesel motors had to be used, making the process even costlier.
In their anxiety to maximize yield, farmers used more fertilizers which decreased the fertility of the soil and polluted the water over the years. Theoretically, industrial infrastructure is supposed to take over from an agricultural revolution after the latter has sustained a society for a fixed period. This is what happened in large parts of America, Europe and Asia and in many Indian states, including Punjab’s neighbour, Haryana. The so-called Green Revolution on the scale of a revolution was not expected to last forever by any account. As predicted by experts, the gains plateaued in the early 1980s, started to decline in the ’90s and by the first decade of the new millennium the party was over. In Punjab, unlike elsewhere in India and in the world, there was no industrial backup to buffer the decline. Since it is a border state, which had borne the brunt of two vicious wars with Pakistan in 1965 and 1971, Indian industrialists had mostly stayed away from investing here.
Whatever little industry was already there fled during the decade and a half of the violent, armed insurgency that gripped the state during the 1980s and the early ’90s. To make matters worse, the central government offered tax benefits for starting new industries in the neighbouring state of Himachal Pradesh and as a result, many factories from Punjab shifted there.
Meanwhile, the small farmers became marginal and the marginal farmers became labourers in nearby grain markets or took on other jobs. These were early signs of a process of ‘de-peasantisation’ which continues today. My patient, Navjot, was just one among the hundreds of thousands who were extruded from farming and suffered terribly since the backup safety net of the industrial sector was missing.
Punjab by then had a large number of youngsters belonging to rural families, who either did not have a family farm to run or very often did not want to join their fathers in farming because it was too much hard work for too little money. Many of them joined these new colleges and so-called deemed universities located in glossy buildings. In many instances, families like Navjot’s mortgaged or sold a piece of land to admit their sons or daughters to these courses. Many of these degrees are not worth the paper they are printed on because whatever is taught and learned is not skill-oriented and there is no match with what the job market requires. All that these teaching shops do is substitute a large number of under-educated, unemployed youth in Punjab with educated, unemployable youth at a considerable cost to families.
The state was like a rich man who had become a pauper overnight. The people of Punjab, particularly the villagers, collectively as well as individually faced a situation where the old norms of life were no longer possible. And society was still struggling to put in place new norms and social support, leaving individuals rudderless. It was not just about money; it was equally about normlessness.
In Punjab after the late ’80s the unemployment rate among rural youth had reached 16 percent and that did not include the very large number of under-employed. Something had to give. Left with almost nothing to do, it would have been surprising if drug addiction had not peaked dangerously and acquired such a destructive form among the young men of that and successive generations. To make things even worse, unlike in animals, the relationship between social isolation and addiction is bi-directional in humans. Social isolation leads to addiction and addiction is highly stigmatizing and abhorrent to society. This leads to further social exclusion of these people, which worsens the chances of their breaking free of the grip of addiction, thus creating a vicious cycle.
Dr Johl sees a way out of this quagmire. He has formally submitted a blueprint (several times), to the government to pull the state out of the economic mess. It essentially involves taking medium-scale clean industry to villages and establishing ‘farm service centres’, which the farmer could approach for getting his farm tilled, harvested and the stubble taken out, at charges approved by the government.
‘To be able to use technology every farmer does not have to own these machines,’ Dr Johl insisted.
‘Why does the government not act on the blueprint?’ I asked.
‘Because the bureaucrats think they know everything.’
‘And the politicians?’
‘No long-distance vision. They can only see as far as the next election,’ he put it simply.
I asked him about the addiction situation in the rural heartland in the old days. He told me that he was nineteen years old at the time of the Partition when he moved from a village in Lyallpur in Pakistan to Indian Punjab with his parents. At that time, opium cultivation was allowed in Punjab although a licence was required.
‘We did not have any money. It was opium that saved us. We had two small fields, in one, we grew sugarcane and in the other opium. Our baithak (sitting room) used to be filled with sacks of opium husk, some of which the farm labourers consumed during harvest weeks, after which they worked tirelessly. The wastage of the husk was thrown away, which the donkeys belonging to the kumhars ate, and they worked non-stop too,’ he said with a smile.
On a more serious note, he added, ‘It was all legal. There was opium all around us, both in the fields and stacked in jute sacks in the house. None of our family members became addicts. Even farm workers who consumed it during harvest season did not become addicts. And now it is illegal and it costs a bomb. Taking it can mean going to jail and yet there are so many addicts. Doctor Sahib, availability of drugs has nothing to do with addiction. Rajasthan grows a whole lot of opium and we do not grow any. If it was availability, why are we addicts and they are not?’ he asked.