Good afternoon, I'll have to ask for your subra or patience, because I'm the what's between us and lunch and the hard act to follow.
Returning you to more prosaic worlds of mental health, but with its own kind of frenzy, hopefully.
But thank you so much, Professor Linda Pramila, for inviting me.
And Claire for helping us with so much and being patient with us.
And it's been a real honour.
It is a real honour to be part of a conversation in which so many people doing such defining work on mental health in India,
who had only ever either known of their work location of or only read or heard about, like Banyan Dr. Pataudi.
So it's a great honour to be part of a conversation in which the people doing such amazing work.
It was a real learning experience. Thank you.
My talk is focussed on a theme that's often at the edges of mental health or mainstream mental health discourse,
namely addiction, specifically heroin and opioid addiction.
How does an issue come to be felt as urgent? Sometimes it's just a simply result of death tolls.
Although there's often a politics of death in terms of what kinds of deaths count as newsworthy.
So we then sort of transnational circuits of newsworthiness. Addiction has gone more into global consciousness in the last few years through what
is called the opioid epidemic in the United States opioid related drug overdose,
as many of us know as the highest cause of untimely or accidental deaths in the United States.
And as the by now quite strong scholarly and popular literature in the US describes it,
the opioid crisis came as a shock to middle class white America in the last decade or so,
entering the body politic mostly through the route of opioid painkillers prescribed
for conditions as innocuous as carpal tunnel syndrome and post-surgical recovery.
After the legal supply was cut off by health insurance,
large numbers of white American patients found themselves seeking out urban underworld in search of opioid substitutes,
most often black dog heroin said to come from Mexico. Discussions on opioids so far remain quite nationally focussed and US centric,
rather than comparative or global, which is what opioids potentially or actually are.
As a first step towards a global conversation or understanding some kind of a map of the contemporary,
we might remember that opioids are not inherently pathological.
They are part of a spectrum of substances that are quite central to a kind of contemporary ecology
of mind within larger world histories of the substance based management of pain and well-being.
As the philosopher Jacques Derrida reminds us, the word pharma gone from which the word pharmaceutical comes is derived.
It means both remedy and poison.
When does the remedy turn into a poison in a biological or a social sense, rather than taking a position for or against pharmaceuticals,
but say we might focus on particular substances and ask what kind of an object heroin or opioids are as distinct,
say, from Prozac and other mood altering substances on which there has been rigorous philosophical discussion,
or at least some philosophical discussion in terms of what the moral objection might be to pharmaceutical induced happiness.
All the darling of pain. One objection to opioids is the propensity for abuse, overdose and death tolls.
Contrary to popular misconception that people in the so-called non-Western more
circumspect about consuming pharmaceuticals as distinct from people in the West,
it's clear. And just to give you an example, over the last decade, India has emerged as the world's leading the highest consumer of antibiotics,
according to the W.H.O. World Antibiotic Report, outpacing China and the United States in relation to prescription painkillers.
The prognosis in India is quite worrying. Amongst other phenomena occurring under the radar of public scrutiny is likely.
The Modi government has gradually been widening the domain of legally available prescription opioids,
in particular by revisions to the National Drugs and Psychotropic Substances Act of 1985,
amended in 2014 and in 2018, stating quote This is from Health Ministry, but not written by Kishore.
Hopefully it was the need for pain relief is an important obligation of the government and quote.
The revised Independence Act creates a list of essential narcotic drugs now available or gradually available with chemists,
including fentanyl, oxycodone and codeine. Many of the key actors of the American opioid epidemic.
And so we might ask, is India ready for or already going through an opioid epidemic?
As an anthropologist, before I answer the question in as much as anthropologist,
never answer the question directly, I should tell you my ethnographic context.
I spent July 2015 to July,
August 2016 as a visiting faculty member of the Department of Psychiatry of the All India Institute of Medical Sciences Ames in Delhi.
And even for those who know if Ms.
It may still be a source of surprise to consider that it is one of the few or last remaining democratic health care institutions,
at least in North India,
where as many patients will jokingly assert any one from a prime minister to a homeless person may be found seeking treatment.
Ms Psychiatry also runs the National Drug Dependence Treatment Centre, the leading Centre for Addiction Psychiatry in North India.
While it aims a key location of my ethnographic work with the urban poor neighbourhoods of property and then agri in East Delhi,
where the AIM psychiatry department runs community clinics focussed primarily on heroin addiction,
the body is particularly infamous in Delhi as a space of crime and smack or heroin addiction.
It's remembered by many as the site of the highest death toll in the 1984 anti-Sikh riots and
has had a major Hindu-Muslim ride as recently as 2014 and periodic skirmishes every few months.
Also administratively to look for reasons and then agree what I call resettlement colonies.
Government answer settlements and with slum dwellers were forcibly or sometimes voluntarily removed from
more gentrified parts of Delhi to small residential blocks in what was then the outskirts of the city,
most famously in urban beautification drives during the period of Indian history,
known as the emergency from nineteen seventy five to seventy seven when democratic rule was officially suspended.
Although many would argue that the situation is now much worse when the Modi government in power in India.
So to return to the question is India going through an opioid epidemic?
In recent media reports in India and abroad, Punjab is often depicted with sensationally high figures,
which have come to be disputed in Indian Addiction Psychiatry because it was founded
to one empirical study on which these news reports are dramatic news reports.
The best was in only three districts of Punjab said to be the drug epicentre of the state.
Besides, number of overdose deaths nationwide are hard, harder to quantify because deaths, particularly amongst homeless in India,
are often registered in mortuary records as calls unknown or with entries like death by exposure to cold or to heat, depending on the season.
And we tried to track some of the mortuary records. But uncertainties notwithstanding, the numerical situation is not entirely unknown.
There have been only two national surveys of heroin use in India so far.
In 2014, a more recent study in 2019 that was overseen by one of my hosts and co-authors, Dr Ravindra Rao at Ames this this survey, the 2019 one,
covered two hundred thousand randomly selected households in 186 districts across all 36 states and Union Territories,
alongside interviews with 72000 drug addicts. Some of the findings of this 2019 survey are quite startling.
The prevalence of opioid use in India is three times the global average.
About 2.1 per cent of India's population use opioids more than Punjab.
Whatever. This has the highest number of people in opioid use problems,
although in terms of the percentage of population affected, the worst affected states are Mizoram and Nagaland.
What kinds of diagnostics might anthropologists offer to these quantitative aggregate pictures of affliction?
One straightforward question would be, for instance, what are the modes of production for heroin in India?
The transformation of opium into heroin or smack is dated to the mid-1980s, when it first became available via Afghanistan.
According to the narratives of all the addicts and sellers, many of whom I also interviewed and then gradually began to be produced locally,
in particular in Uttar Pradesh, Rajasthan and Madhya Pradesh, the three states in India,
historically where poppy can be grown legally for medicinal purposes.
Part of the legal poppy harvest is then siphoned off for the production of heroin,
which can be synthesised as it often is in North India in one room cottage industry type units.
So it doesn't take a very large production unit beginning as what used to be called the hi fi nature or a foreign press.
In the last two decades, heroin has emerged as the most common drug abused by the Indian urban poor, quite literally opium for the masses.
Within the ecology of drug abuse in India, we might ask what are the available forms of treatment?
Perhaps the least repressive form of pharmacological treatment is what is offered by MS and Gizzi in their community clinics in the locality,
and some then agree a form of treatment globally known as opioid substitution therapy or steam treatment,
a form of treatment where a heroin addict is given a regular dose of a less addictive and more economically manageable substitute opioid.
Strange as it may sound to substitute one opioid for another, OCD treatment can literally be lifesaving for individuals and for households,
even with the accompanying danger of OCD medications being resold in open markets as narcotics,
which is often a suspicion in India and many other parts of the world.
The first OCD clinic in India began at Ames in 1990, funded by the W.H.O. Ministry of Health and Macko that present only 215 OCD clinics in India.
In contrast to the treatment that are outpatient based,
a much more worrying phenomena across urban India that's emerging is the mushrooming across Indian cities of unregulated,
private and national thinking. The addiction centres, which many of you are familiar with Indian cityscapes,
might have seen or almost not noticed because it's so common that most often these are
advertised on walls of public spaces with little more than just a cell phone number.
And there's a reason why there's just a cell phone number. These centres are mostly just spaces of incarceration.
One would often hear of the sudden deaths of young men in these centres or relapsed soon after release with no recourse except for incarceration,
usually at a very high monthly payment by the family members of a heroin addict.
Alongside statistical aggregates and emerging institutional technologies, what might an anthropology of addiction look like in the case of India,
which as many of us know is a well-developed sub field in other parts of the world?
And these are some of the well-known books in the anthropology of addiction.
And what could enhance value of addiction offer to broader conversations like these?
If in the social sciences we are to offer questions and methods and specific and
rigorous yesterday as I quantitatively driven our city oriented colleagues.
So methodologically, if we were to try and give you problems and that like the problems you give us,
I'll offer one ethnographic puzzle from my own fieldwork,
which offers the kind of research agenda in better understanding the at times strikingly sharp variations in patterns of drug abuse in seemingly
contiguous areas and particular forms of life and death linked to a substance like heroin in India and in many other parts of the world.
The instance I'm giving you draws on two chapters of the book I am currently writing.
Some parts of it may seem very theoretical and philosophical, so I'm happy to clarify both of the chapters.
I'm drawing on a collection of neighbourhood fall sick and heroes and heroine.
The first of these chapters focuses on a seemingly local difference between two locally and Swindon agree.
Whereas I said MS Also-rans or SD community clinics. Initially, I focussed for many months only on three local reason.
That's the primary field site for my next book. But an additional ethnographic imperative was posed to me with some urgency by my horse.
Psychiatry faculty and residents at Ms. Say you have to visit our other clinic.
Many of them would soon do a study to tell us why it's so different from this one, from local look different in what we asked.
It's much more dangerous, they said. Intriguingly, this other, more dangerous clinic was Swindon, then agreed 12 kilometres away,
also settled in the same year as the opening during the emergency in 1975 76.
Demographically quite similar as our household surveys in 100 households in each of the
two neighbourhoods also seemed to show a demographically quite similar settlement.
Quite similar on first impressions. The Swindon clinic did have a much edgier atmosphere.
Fights would break out more often. Patients often threatened the doctors and staff mobility with knives.
The patients, all male, were gone to and had hollow are more ghostly eyes of the kind.
I hadn't seen interlock pretty. There were much fewer accompanying mothers and wives,
one often encountered intellectually rather than only a psychiatrist by our knowledge, construction of risk and normalcy in time,
I found that the difference between these two neighbourhoods would also be
posed in more importance in the language and experience of addicts themselves.
So as most national bars or smack addicts will describe it or tell you anywhere in the world, there are three ways in which you can ingest heroin.
You can smoke it, which is relatively expensive about 250 rupees a piece in India.
Or you can chase it on a foil or pani, which is about a little cheaper 200 rupees.
And after that, in a downward hierarchy that most addicts can form in a different category from smokers and Jesus Gandhi
inject injectors with sweet injections and she-she bottles with heroin and pharmaceutical cocktails,
which you would get from a chemist and not from a smack dealer. And this swishes sect, as it's called you would get four rupees, 40 or less.
That is one-fifth the price of the smoker or Chaser's habit, as most addicts and psychiatrists will put it.
But addicts often tell you that Jesus life is Daniel's long and injected life is two years at most.
Addiction psychiatrist would agree, pointing to various vulnerabilities for injectors, including most prominently from a global health perspective.
The risk of contracting HIV or hepatitis B through shared needles.
So what we have are two different, sharply different modes of heroin consumption.
Smokers and j cells on the one hand and injectors on the other hand,
methodologically based on repeat interviews over the last few years and patient files
and days and nights that I spent in both neighbourhoods with frequency cause addicts,
male and female residents, as well as household surveys in both neighbourhoods.
The initially intuitive difference emerged more sharply. The luxury had barely a single injector, and I say this after visiting every smack dealer,
every hot, hot spot as it's called in the neighbourhood where addicts would hang out.
In contrast, and then agree, used injections could be found everywhere,
strewn in ordinary neighbourhood spaces such as box all over the neighbourhood.
Numerically, the difference is quite stark.
According to clinic figures, out of three thousand one hundred thirty eight patients in the locality that only four injecting drug users,
as they call it, use or VW IDs and six HIV positive patients.
In contrast, in an aggregate of a total of one thousand seven hundred seventy three patients,
300 are ideas and 137 on HIV positive on a national scale.
Ideas show a much higher rate of HIV even than commercial sex workers, often assumed to be the primary drivers for the spread of HIV.
As I put it, a Jesus, life is 10 years long and inject us life is two years at most.
Conceptually, we might rephrase the question in relation to one of the founding texts of social theory.
Emil Durkheim suicide, which had compared contiguous districts in Europe.
To ask, I quote how a definite number of people killed themselves in a particular way repeatedly over time,
and how these forms of death vary, sometimes quite sharply between seemingly proximate areas.
Interestingly, these sharp regional variations in opioid consumption exist across different geographies across the world,
for instance, across neighbouring states, in the United, in the U.S. and in the northeast of India,
where similar social conditions yield sharply differing differing forms of addictive vitality, objection and death.
So how did this happen? In a presentation of this land, I promised you an interesting question, but not necessarily an answer,
but I can at least offer a few hints in the case of Re-look Pourrions and then agreeing the difference,
as with many things in South Asia, is partly or quite crucially,
to do with cost and the different occupational composition of these two neighbourhoods.
Mostly salaried Valmiki origin, as Gandhi had called it, the government employed sanitation workers.
In the case of trilogue, Puri, who can sort of afford the more slightly more expensive mode of consumption of geosynchronous smack,
as opposed to the much more unstable, informal economy of southern agri that tends towards the cheaper option of injecting.
But that is only part of the answer because there is also a spiritual or metaphysical factor involved that is not only economically determined.
For instance, the very different forms of death and mourning that I found across these two neighbourhoods in relation to heroin.
I'll end with a contrast between these two forms of death and mourning. Amongst former addicts, interlock Puri.
I'm the person I'm closest to is popularly known as Asif Kabbalah.
CNN's very well-known kebab shop in Block 27, which is the Muslim god of the heart of the local artists.
Younger brother Sultani died of an injection overdose in January 2008,
as did his closest friend and neighbour Irrfan, nearly every member of his family.
Separately, in separate interviews, his father, mother and brother had described these deaths to me.
We detail that as I heard, it constituted a kind of mourning satanic screams the night before,
with 210 breaking the word for heroin withdrawal, 100 rupees that his father gave him, unable to bear his screams.
All this happened two days before OEB, all that was cooked for EDTA. The two days with Sultani disappeared how he died in a garbage dump.
I have heard about his death from the whispers of smack addicts in another public bathroom, how they rushed to the hospital to claim Sultan his body,
how his body was about to be cremated in the Hindu way when they reached the morgue just in time.
A few months later, Asif gave up Ganja and SMAC and became part of a gang that beat up the remaining injectors in parks and public spaces.
The dental opening by 2009, just a year after Sultan, is that there was not a single injector left interlock puri.
That said, even now, 10 years later,
Arthur still comes to collect his bi-weekly twice a week buprenorphine or doors from the three luxury AIDS clinic,
Sudan agrees also saw a number of such deaths.
And while outreach tracked treatment dropouts over time, I found that they'd been much more of these deaths in Sudan agree the deaths.
The high heroin related death toll in some degree is much higher than three of the deaths in Sudan agreed were not unmarked,
but living companions continued along a different trajectory of compulsion and forms of life and death.
For example, I became quite fond of Imtiaz and Injector, and some don't agree.
Twenty years old said to be a very talented pickpocket adept at stealing cell phones,
usually working with two friends, Waseem and Jordan, both of whom died during the course of my fieldwork.
The most common occupation for heroin addicts in Delhi,
even in clinic when they have to say occupation, the most common occupation is listed as pickpocket.
Although it's an effort by its practitioners, by the more euphemistic term trash pockets such in the code language spoken
by pickpockets in Delhi is known as Farsi and a team is known as a company.
Jorhat amongst India's Waseem Johar was the machine or head of the gang, and Imtiaz Admiringly described it.
Jihad would only on come on. It's hard to pick what only on quality items like.
If it was a small mobile phone, you would throw it back on the ground and tell the person they dropped their mobile.
He was a real artist. Contrary to resumptions of familial abandonment, Imtiaz and Johar both had relatively supportive families.
They tried almost every legal occupation possible instant an angry waiter, electrician,
shop assistant, etc. In these jobs, they carried on about 150 rupees a day.
In contrast to hours on the road and one cell phone could bring 10000 rupees or more, depending on the resale value of the phone.
In 2015, Imtiaz, his parents, made a major attempt to get him out of all this and to separate him from the game.
They took a loan of 80000 rupees and bought him in order to accept that was stolen.
A few days later, and Imtiaz relapsed the day after Georgia's death.
After shedding tears with me and others in the clinic, Imtiaz rejoined an older injector called Chatah,
whom he had distanced himself from after Jadeja had left him bleeding in a ditch to be rescued by the police.
Six months ago? I hesitate to call this death without weeping as Nancy Shepherd, you call it famously in another context.
Maybe there is no way to compare impulses,
deals with ourselves or what others might have become had he lived in Swindon agree, rather than to look boring.
Instead, we might say that they're forms of life and forms of debt that we become part of, depending on a local ecology.
These local differences can be nationally significant, as we saw earlier with the figures for HIV in India and similarly sharp variations,
as I'm saying, exists globally in ways that would require an emotion in other kinds of ecological detail.
Anthropology, we might say, is addicted to the pursuit of this kind of local detail,
which are not irrelevant at all to the so-called larger conceptual picture.
For instance, the concept of an epidemic may not be the best done with which to understand the spread and contagion of opioids,
since the spread may be sharply differentiated as I'm across neighbouring regions in India and in the United States and many, many places.
Also crucial would be to think about four strategies of intervention in relation
to yesterday's discussion on ecology and also trying to think of the ways
in which the idea of a neighbourhood might be significant as a unit of analysis
in an ecology of mind or Gregory Beetson had called an ecology of mind.
A specific ecologist will offer more differentiated routes into questions.
Also, as I am suggesting of global health, such as Is there an opioid epidemic in India?
My answer yes. Will it get worse? Probably much worse.
What can be done? At the very least,
there is a need for better regulation of these so-called national addiction centres that approve proliferating across Indian cities at the moment.
Conceptually, what is the rise of opioids mean globally as a map of the contemporary?
What kind of psychic distress is being expressed here? What is it?
A symptom of the usual answer in the anthropology of addiction is to gesture to some variation of alienation, objection and neoliberal abandonment.
But if that were the case, then we wouldn't see such sharp variation within so-called neoliberal culture.
And further, in the long run philosophical and ethnographic consideration of heroin in my book,
which is too long and complex to describe just quickly about how heroin relates to its root word heroin.
The German word heroic as an experiment with vitality.
Happy to talk more about that, but that is for another occasion.
For now, I hope you have emphasised both the global scale of the question concerning opioids,
but also the enduring and logical fascination with the variation and the anthropological field that the world is not flat.
Thank you.