This is the first in a two-part interview with Professor Richard Velleman about his work in addiction treatment services and research in India. This part talks about how addiction, or de-addiction services are run.

SSA: You have worked in India in addiction treatment and research, how are those services run?

Prof. Velleman: “There’s a number of things to say, the first is that they don’t have ‘addiction services’, they have ‘de-addiction services’; because, why would you want a service for addiction, when you want to stop addiction? So, you have de-addiction services.”

Somebody might travel for 2 days to get to the de-addiction centre, and then 2 days to return home; so, there’s no way that they’re coming back for a follow-up session

“Unfortunately, India continues to be influenced by some of the worst characteristics of its colonial past [Editor’s note: India was under direct rule from Britain between 1858 and 1947]. As you know, in the long distant past, all addiction services in the UK were based in large psychiatric hospitals that had addiction treatment units in them. So, there were regional alcohol treatment units (because there weren’t really major problems with other types of addiction in those days). Those units ran up until the 1960s and then gradually community alcohol services started and were developed. And I’m sure you know the history of addiction services in the UK very well. India, however, is stuck in the model that we had in the 1950s, with primarily quite large regional in-patient de-addiction centres.”

What kind of treatment services are available?

“There are very few addiction services, and almost all of those that exist are funded by the state. As I have just outlined, almost all of them are large tertiary institutions in large conurbations. There is at least one de-addiction unit in each state – but don’t forget, a state can have 140 million people, so when I say there’s at least one in each state, it gives you an idea of the massive catchment areas that each will have to cover.”

“There are also some private de-addiction units, and these are also quite large and are also based in major conurbations. So, Hamid Dabholkar, (a psychiatrist who I worked on the Premium study – see sangath premium) ran a private de-addiction unit in Satara (which is a large city in Maharaja).”

“But the standards of psychiatric care overall, and of addiction care as well, across a great deal of India are very variable.  Even when I was in training in the UK in the 1970s in a variety of large in-patient psychiatric and learning difficulties hospitals, I had not seen people chained to their beds. I had heard about this practice in Victorian times, and read about it still occurring in some countries, but it was not part of recent UK memory. Yet in India, I have seen people chained to the bed, not because the staff were cruel but because they didn’t have medication to deal with people who were having psychotic breakdowns. It was certainly an eye opener and a shock.”

“This rarely happens in Indian de-addiction services, but certainly could happen, in cases where someone was suffering from violent DTs and where no medication was available. But even leaving that aside, most de-addiction services in India are similar to the worst sort of in-patient detox that we have in the west. By this I mean that the service brings somebody in, they will stay as an inpatient for a bit, and if they are lucky they will get some medication to deal with withdrawal symptoms for the first part.  That person might remain as an in-patient for 1 week, 2 weeks, 3 weeks (depending on the ‘programme’) and they may get some sort of ‘group therapy’ help, or some AA attendance; and then they will get sent back home, with no follow-up.”

One of the key things that Vikram was very interested in was, to what extent was work that had a good evidence base in high income countries transferrable to low and middle income countries

“The lack of follow-up is not deliberate but given the huge distances that people may have to travel to get from their village or community to the de-addiction centre, and to return back after ‘treatment’, there is no real possibility of follow-up. Somebody might travel for 2 days to get to the de-addiction centre, and then 2 days to return home; so, there’s no way that they’re coming back for a follow-up session; and almost no services have any community provision to allow them to follow-up people once they have left the institution.”

What are you trying to develop in the services you work with in Goa?

“What we’re trying to do is something which is very, very different; which is to develop community-based services, and to partner with both local communities, and with primary care; and to develop local evidence as to what works in India (and in our area of India) as opposed to simply introducing western methods on the assumption that even good evidence-based western methods will be transferable to our context. I started in India with a very naïve view. As you know, in the UK, most addiction services are dealt with initially in primary care, whether that’s initial advice and information or even prescribing and so on. We know that primary care doctors can and do get involved. So, when I started in Goa, I saw that we were already screening people in government-run primary care, so it seemed obvious that we’d got some sort of entry into primary care; so, I assumed that we could simply work with primary care to develop primary care-led services.”

“When I said this in Goa, my colleagues looked at me as if I was from totally another planet and said ‘it’s not quite like that here’ let’s go and sit in some of these public primary care services. So, we went, and I sat in.”

Working in the public/government sector is also not very high status: one of my doctor friends in India said to me, ‘nobody I know would take a job as a doctor in a government run primary care facility’

“As an aside, the first thing that struck me was that they don’t have the same sort of privacy issues that we have in the west, hence I was allowed (as a visiting ‘expert’) to simply sit in, in the consultations. There is often a huge queue of patients, waiting to see the doctor.  In the primary care centres that I visited, the GP doesn’t see just one person, they will see three people at a time: they’re not related, just the next three people in the queue.  The patients file in and the GP will rarely ask them what’s wrong, and certainly not in any detail: the GP may look at them and do some sort of investigation in front of the other two people, and then the GP will tell them what they need to do and that’s it. It’s a very different, very paternalistic and expert-centred model.”

“Working in the public/government sector is also not very high status: one of my doctor friends in India said to me, ‘nobody I know would take a job as a doctor in a government run primary care facility’. The suggestion was that people with ‘gumption’ tend to go into private practice or come up as a consultant, probably also still working in private practice, although they might do a bit of work in a government hospital as well. So, it becomes a negative spiral about working in publicly funded health services in India. That all leads to a situation whereby doctors who work in publicly-funded primary care settings can become unmotivated. So, against that backdrop, the ‘simple’ idea of recruiting interested GPs and other staff in publicly funded primary care to act as the first line of assessment and intervention is still a long way off.”

So, what about the work at Sangath?

Vikram Patel is probably one of the most globally important people in mental health. He set up Sangath with other colleagues about 25 years ago and turned it into a very unusual NGO [non-governmental organisation]: a research-based NGO. He felt that there were a lot of NGOs in India which were trying to develop and improve services, but that the problem was that there was very little research-base as to what might work in India (and other low and middle income countries). He wanted to create an organisation that undertook research about how to develop better services for low and middle income countries, generally, and particularly for India. He’s a psychiatrist and his initial work was in depression; and a lot of his subsequent work had been around depression and common mental health problems, although he is very wide-ranging in his research and his interests.”

“One of the key things that Vikram was very interested in was to what extent was work that had a good evidence base in high income countries, to what extent was that, in any way, transferrable to low and middle income countries.  What he didn’t want to do was to develop a system where you simply imported work, ideas, theories, interventions that had been developed in high income countries and transferred them into low income countries and imagine that they would work. So, he realised that he needed to develop an evidence-base over what worked in low and middle income countries, and how to develop culturally-relevant yet still evidence-based interventions.”

Part 2 will cover Professor Velleman’s work at Sangath researching how treatments developed and researched in the west are made culturally relevant, tested and disseminated to treatment services in India.

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