Facing the Unknown: The growing effort to shed light on Sikkim’s substance abuse and suicides

(Had a great time doing this piece last week, especially after meeting Dr. Linda Cottler, from back home in STL. It was the cover story in Sunday’s NOW magazine.)

This may be conventional wisdom in many circles, but Sikkim has a problem with addiction. Substance abuse of alcohol, prescription medications and more unconventional (and dangerous) drugs are all reportedly on the rise. So are suicides. Unfortunately there is little hard data to help government programs, NGOs, health experts and social workers understand how to tackle these problems.

“Substance abuse is a very big problem,” says Dr. Kumar Bhandari, the Director General of Health Services and a cardiologist at STNM Hospital. “However, all the evidence we have is anecdotal.”

Anecdotes are useful in raising awareness and helping people understand the pressing human nature of these issues, but they leave a lot of ambiguity. In Sikkim it isn’t even clear how many drug overdoses are accidental, how many are the result of addiction, and how many are attempts at suicide. Without statistics on who is committing suicide or abusing drugs, where and under what circumstances, we have little idea what social factors are causing these deaths.

“I wish we knew the reason,” says Dr. Bhandari, “but it is so multifaceted.”

In an effort to begin the long process of answering these critical questions, a five-day symposium-cum-workshop on “Health Research Methodologies” and “Modular Training on Substance Abuse Prevention” was held this week at Hotel Denzong Regency in Gangtok. The goal of the conference is to start building the infrastructure for research on addiction in Sikkim. Organised by the Sikkim Anti-Drugs Unit of the Health Department in collaboration with the ICOHRTA program of Fogarty International Center and the US-India Educational Foundation, the conference was the brainchild of Dr. Tekendra Rai, the program officer of the Anti-Drugs Unit. Dr. Rai — himself a Humphrey Fellow who has trained and worked on addiction research overseas — brought together four more experts from Australia, the United States and Bangalore, as well as a representative from the Indian Council of Medical Research, the organisation which vets the procedural and ethical quality of health studies done in India.

“We know we need empirical research, but I found people disinterested,” says Dr. Rai. “So I said, ‘let’s build their interest.’”

The 60-plus daily participants included government officers, academics, psychiatrists and social workers from all over Sikkim, plus a few from the greater North East region. The conference featured three days of discussions, talks and workshops on substance abuse in Sikkim and research methods of studying addiction. Attendees were asked to come up with specific questions about local drug problems that they wanted answered; nearly all responded enthusiastically. Thursday and Friday put specific participants through the more structured SAMHSA training program developed by the United States Department of Health and Human Services.

“It has been like seeing Kanchenjunga early this week,” says Dr. Linda Cottler, an American expert on addiction and one of the visiting resource persons at the conference. “At first things were very cloudy, but each day it has become more visible, more focused.”

Dr. Cottler is Director of the Epidemiology and Prevention Research Group at the Washington University School of Medicine in my home town of St. Louis, Missouri. She has worked on addiction research training all over the world: Bangalore, Bangkok, Taiwan, Australia, and of course the United States. In Bangalore she works under a Fogarty grant to train mental health professionals at NIMHANS, the National Institute of Mental Health and Neuro Sciences.

“I’m here to recommend how to ask questions,” she says. “That’s what we spent three days on.”

Asking questions might sound simple in theory, but in practice deciding what to ask and to whom gets complicated very quickly. For instance, a simple survey of school children would necessarily be incomplete, as many of the kids involved in substance abuse have dropped out of school. Too little is known about this wayward group, not even which came first: did they drop out and start taking drugs, or did they start taking drugs and then drop out? Any survey effort undertaken would need to be able to find these youths and approach them in a way that ensures trust and honest participation.

In the United States, where prescription drug abuse has also been on the rise, Dr. Cottler works on surveys of kids at entertainment venues like malls, skate parks and arcades — what one might call the “third spaces” where young people spend their time when not at home or in school. Researchers first asked questions about how often the subjects ate with their families and whether they played sports. Then they showed pictures of different pills and asked if and how often they had taken each in the past 30 days. The last few questions would ask the kids for their own ideas on preventing substance abuse.

“What Sikkim wants to do is prevention in secondary school and younger, but you have to know how to make it relevant. That’s where the survey comes in,” Dr. Cottler says. “But it starts with finding where kids are.”

The need for a proper and comprehensive survey of addiction in Sikkim was a common concern among all the experts I spoke to. Without one, any efforts to prevent addiction in the state might as well be shots in the dark. Unfortunately the push for development in India and Sikkim specifically is often so frantic and even single-minded that research is usually given a fairly low priority by the government. Academics are more interested, but so far they have lacked the resources and training in specialised methodologies to carry out an effective effort. Addiction workers in Sikkim also need to be taught how to go about applying for funding for their projects, as navigating the national and international bureaucracy of medical research grants is a specialisation all its own.

This week’s conference hoped to take some of the first steps towards correcting these deficiencies. Luckily those I spoke to thought that the participants were getting a lot of the event. There was lots of networking going on between sessions, and people were batting around plans to start an “Indian Society on Addiction” — an organisation which currently does not exist.

“We are a closed society. This sort of thing opens eyes,” Dr. Bhandari told me at Wednesday’s symposium banquet.

Dr. Tekendra Rai also presented a proposal to create a “training in research” division within the Department of Health to Sikkim’s Minister of Health, who inaugurated the second half of the conference on Wednesday afternoon. This division would “build capacity to do research using evidence based practices.”

Sikkim has a long way to go on this road, and all the while substance abuse and suicide rates look to be climbing. Still, there is hope. Addiction is hardly a problem unique to Sikkim or to India; societies all over the globe are struggling to help addicts recover and turn young people away from dangerous habits. There is a lot of work being done, and under the right circumstances Sikkim could be lifted by those giants’ shoulders very quickly.

“I think there are more similarities in the world than differences,” says Dr. Cottler. “We have to tweak our methods to account for cultural differences, but kids have similar brains everywhere. They aren’t bad kids, but they make bad judgements. Our job is to find out what we can do to help them make a change.”

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